Sexual Risk Behaviors Research Paper

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By the mid-1980s, the menace of AIDS had made indiscriminate sexual behavior a serious risk to health. Under certain conditions sexual behavior can threaten health and psychosocial well-being. Unwanted pregnancies and sexually transmitted diseases (STDs) such as gonorrhea and syphilis have long been potential negative consequences of sexual contact. Yet today HIV infection receives most attention. Because of this, this research paper will focus on the risk of HIV infection through sexual contact, while HIV infection through needle sharing, maternal-child transmission, and transfusion of blood and blood products will not be addressed. This research paper is divided into five sections. Section 1 defines sexual risk behavior and delimits the scope. Section 2 discusses the research methodology in this field. Section 3 presents epidemiological data on sexual behavior patterns and HIV infection status among relevant population groups. Section 4 examines the determinants of risk behavior. Section 5 concludes with a discussion of strategies for reducing risk exposure.

1. Definitions

Sexuality is an innate aspect of humanity and is oriented toward sensory pleasure and instinctual satisfaction. It goes beyond pure reproduction and constitutes an important part of sensual interaction. Sexual behavior embodies the tension between biological determination, societal and cultural norms, and an individual’s personal life choices. Sexuality and sexual behavior are subject to constant change. Sexual mores and practices differ widely both within and between cultures, and also from epoch to epoch. One defining feature of sexuality is, therefore, the diversity of sexual conduct and the attitudes surrounding it.

Sexual risk behavior can be described as sexual behavior or actions which jeopardize the individual’s physical or social health. High-risk sexual practices, such as unprotected intercourse with infected individuals, constitute unsafe sexual conduct, and therefore deserve to be classified as a health risk behavior or behavioral pathogen (Matarazzo et al. 1984) on a par with smoking, lack of exercise, unhealthy diet, and excessive consumption of alcohol. Among the STDs, which include gonorrhea, syphilis, genital herpes, condylomata, and hepatitis B among others, HIV infection and AIDS are by far the most dangerous. It has linked love and sexuality with disease and death. If an HIV-infected person fails to inform a partner of his or her serostatus (positive HIV antibody test), unprotected sexual intercourse resulting in the partner’s infection has also legal consequences.

In general, unprotected sexual intercourse (i.e., without condoms) with an HIV-infected partner is of risk. HIV may be acquired asymptomatically and transmitted unknowingly. There is a ‘hierarchy’ in the level of risk involved in sexual practices. High-risk sexual practices include unprotected anal intercourse (especially for the receptive partner) and unprotected vaginal intercourse (again, more for the receptive partner) with infected individuals, as well as any other practices resulting in the entry or exchange of sexual fluids or blood among the partners. Oral sex, on the other hand, carries only a low risk. Petting is not considered sexual risk behavior. The risk of sexual behavior is a function of the partner’s infection status, the sexual practices employed, and the protective measures used. Sex with a large number of sexual partners is also risky because of the higher probability of coming into contact with an infected partner. The risk can be minimized or ruled out entirely by appropriate protective measures: low-risk sexual practices, use of condoms, and avoidance of sexual contact with HIV positive partners.

Sexual risk behavior also applies to the area of family planning. Unwanted pregnancies may occur if the sexual partners do not use safe methods of contraception. If the partners do not wish to have children, sexual contact risks an undesired outcome. Unwanted pregnancy can have consequences ranging from changes in life plans, in the partnership, and in decisions to abort with the ensuing emotional stress and medical risks. Deviant sexual behavior such as exhibitionism or pedophilia cannot be defined as risk behavior.

The analysis of sexual risk behavior falls in the domains of psychology, sociology, medicine, and the public health sciences (Bancroft 1997, McConaghy 1993). Research is available in the areas of health psychology, health sociology and social science AIDS research (von Campenhourdt et al. 1997; see the journal AIDS Care; see HIV Risk Interventions). The terms used in studies more frequently than ‘sexual risk behavior’ are ‘HIV risk behavior,’ ‘HIV protective behavior,’ ‘AIDS-preventive behavior,’ ‘HIV-related preventive behavior,’ ‘safer sexual behavior,’ ‘safe sex,’ or ‘safer sex’ (DiClemente and Peterson 1994, Oskamp and Thompson 1996). These descriptions ought to be given preference over the term ‘sexual risk behavior’ in order to prevent pathologizing certain sexual practices; it is not the sexual practice as such which presents the risk, but the partner’s infection status. Although this term will be used further here, this issue ought to be kept in mind.

2. Research On Sexual Risk Behavior

Assessment of sexual risk behavior is complicated by problems in research methodology. Fundamentally, research in sexology faces the same methodological problems as other social sciences. Studies of sexual behavior require special survey instruments and must take into account factors influencing data acquisition and results (see Bancroft 1997). The most important methods of data collection include questionnaires, personal interviews, telephone surveys, and self-monitoring. None of these methods is clearly superior to the others. The quality of retrospective data depends on the selected period, the memory capacity of study participants, the frequency of the behavior, and whether the behavior is typical. In general, in research on sexuality no adequate external criteria are available to validate reporting. Psychophysiological data exist only to a limited extent, and field experiments and participatory observations are usually not applicable. Since the different survey methods and instruments involve differential advantages and disadvantages, a combination of methods would be appropriate. However, this is often not feasible due to practical constraints including limited resources and constrained access to target groups.

When conducting scientific surveys on sexual behavior, it is important to inform and instruct study participants about the purpose of the investigation. Questions must be phrased in a neutral and unprejudiced manner. For sensitive issues, such as taboo topics and unusual sexual practices, the phrasing of questions and their position in the questionnaire are critical. When surveying populations with groupspecific language codes (e.g., minorities that have a linguistic subculture), it is necessary to discuss sexual terms with the interviewees beforehand. The willingness to participate in the study and to answer survey questions can be influenced by the fear of reprisals if the answers become public. Depending on the objectives of the study and the study sample, relative anonymity (via telephone interview) can play an important role in the willingness to participate and the openness of responses.

Independent of the selected survey instrument, exaggerations, understatements, and socially desirable answers are to be expected, particularly to questions about sexual risk behavior. Study participants report their own behavior based on role expectations and their self-image. Thus, it is important to assess and control for appropriate motivational and dispositional variables, such as social desirability and the tendency for self-disclosure and attitudes toward sexuality. The person of the researcher, in particular his or her sex, age, and sexual orientation, has an important influence on response behavior. For example, for a heterosexual study sample it may be advisable that male participants be questioned by a male interviewer and female participants by a female interviewer. A heterosexual interviewer must be prepared not to be accepted by homosexual participants. This applies in particular when questions address highly intimate sexual experiences and sexual risk behavior.

Generalizability is one of the most serious problems when reporting data from scientific surveys on sexuality. Access to the study sample and the willingness to participate are more closely linked to relevant personal characteristics of the participants (sexual experiences, attitude toward sexuality) compared to other research. Participants tend to show, for example, greater self-disclosure, a broader repertoire of sexual activities, less guilt, and less anxiety than nonparticipants. Since randomized or quota selection are rarely possible, an exact description of the sampling frame is essential to permit an estimate of the representativity of the sample and the generalizability of the results. Generally, study findings are often based on reports by individuals who are, to a substantial degree, self-selected. This must be taken into consideration when evaluating the findings of studies on sexual behavior.

3. Epidemiology

Data on the epidemiology of sexual risk behavior can be acquired from different sources. Numbers can be obtained through studies on sexual risk behavior, focusing on the behavior itself. As mentioned above, methodological problems often plague such studies. Even if rates of condom use and numbers of sexual partners are assessed correctly, they may not provide the specific information needed to present the epidemiology of sexual risk behavior. The finding that about 50 percent of heterosexual men do not regularly use condoms is only relevant if they do not use condoms in sexual encounters with potentially infected partners. This information, however, is rarely available from existing studies. Numbers can also be extrapolated from incidence and prevalence rates on sexually transmitted disease or unwanted pregnancies.

These data focus on consequences rather than the risk behavior itself, and extrapolation to the prevalence of risk behaviors is complicated by the fact that it is sometimes difficult to distinguish how an infection was transmitted (sexual contact, transfusions, or needle sharing). In addition, reporting may be incomplete or inaccurate for the following reasons: (a) not all countries require compulsory registration of HIV infections, (b) cases are often recorded anonymously which may result in multiple registrations of the same case, and (c) there may be a high number of unreported cases that do not find their way into the statistics.

Despite these methodological problems, epidemiological data are necessary and useful for behavioral research. The available epidemiological data on sexual risk behavior from European and US American sources are presented below for five different subgroups: adolescents, ethnic groups, homosexuals, heterosexuals, and prostitutes. These subgroups are not exhaustive, but they elucidate the differences and specificity of epidemiological data on sexual risk behavior.

3.1 Adolescents

Adolescents comprise a special group concerning sexual risk behavior. Their initiation into sexuality may shape their sexual behavior for many years to come. They have as yet no rigid sexual behavior patterns and are subject to influences from their peers, parents, the media, and other sources. Compared to the 1970s, teenagers are sexually active at a younger age. Many teenagers (about 25 percent of males and 40 percent of females) have had sexual intercourse by the time they reach 15 years of age, and the mean age of first sexual intercourse is between 16 and 17 years. Because adolescents are sexually active earlier in their lives, they also engage in sexual risk behavior at an earlier age. The majority have several short-term sexual relationships, and by the end of their teens about half report having had more than four partners. The majority of adolescents report being exclusively heterosexual, but an increasing number of teenage males report being bisexual or homosexual.

Data on infection rates show that sexually transmitted diseases are widespread among adolescents. The human papilloma virus (HPV) is likely to be the most common STD among adolescents, with a prevalence of 28–46 percent among women under the age of 25 in the US (Centers for Disease Control and Prevention 2000). The prevalence of HIV infection is increasing slightly among adolescents, but accurate data are difficult to obtain. Due to its long incubation period, those with AIDS in their twenties probably contracted the virus as adolescents, and such cases are on the rise. Teenage pregnancy is still an issue, although numbers generally have decreased. The numbers are still high, especially in the US, where 11 percent of all females between ages 15 and 19 become pregnant (Adler and Rosengard 1996). Data on behavior indicate that about 75 percent of adolescents use contraception. Adolescents in steady relationships predominantly use the pill, while adolescents with casual sexual encounters mainly use condoms. Most adolescents are aware of the risk of pregnancy when sexually active, and they use condoms for the purpose of contraception rather than for protection against STDs. Most of them have sufficient knowledge about HIV infection and AIDS, although erroneous assumptions still prevail. Personal vulnerability to AIDS is perceived to be fairly low, and awareness of other sexually transmitted diseases is practically nonexistent. Alcohol and drug use, common among adolescents, further influence sexual behavior among adolescents including reduced frequency of condom use.

3.2 Ethnic Groups

There are distinct differences in HIV infection among different ethnic groups. Data on infection rates are available mainly from studies conducted in the US. These show that African–Americans face the highest risk of contracting HIV. Despite making up about 12 percent of the US population, the prevalence among African–Americans is 57 percent of HIV diagnoses and 45 percent of AIDS cases. Almost two-thirds of all reported AIDS cases in women are among African– Americans. The incidence rate of reported AIDS cases is eight times the rate of whites (Centers for Disease Control and Prevention 1999). The Hispanic population has the next highest prevalence rates. Hispanics accounted for about 20 percent of the total number of new AIDS cases in 1998, while their population representation was about 13 percent. Their rate is about four times that of whites. It is likely that differences in sexual behavior underlie these statistics, but most studies of behavior have focused on one specific group rather than comparing them with each other.

Possible reasons for differences in infection rates could be that (a) members of ethnic groups often have a lower socioeconomic status and have less access to health care, (b) they are less educated and score lower on HIV risk behavior knowledge, (c) they communicate less with partners about sexual topics, and men often have a dominant role in relationships, such that women have difficulty discussing promiscuity and condom use, and (d) men often are less open about their sexual orientation and their HIV status compared to white men.

3.3 Homosexuals

Homosexual men (men who have sex with men) are a high-risk group for contracting HIV infection. Estimates suggest that 5 percent to 8 percent of all homosexual men are HIV positive. Unprotected sexual contact among homosexual men accounts for about 50 percent of all HIV infections (Robert KochInstitut 1999). Compared to other groups, homosexual men are more likely to engage in sexual risk behavior, including receptive or insertive anal sex and higher numbers of sexual partners. However, prevention campaigns seem to have influenced the sexual behavior of this group. An estimated three-quarters of homosexual men now report using condoms, especially with anonymous partners. There also seems to be a decline in the overall number of sexual partners. However, some homosexual men continue to expose themselves to considerable risk of HIV infection. Although more homosexual men are using condoms, they often do not use them consistently in all potentially risky sexual encounters. Also, especially those who still engage in unprotected sex are usually sexually very active and/or have multiple partners. Studies on sexual behavior often overlook this fact when reporting rates of condom use. Homosexual women are at practically no risk of HIV infection through sexual behavior.

3.4 Heterosexuals

Heterosexuals in monogamous relationships are at low risk for contracting HIV. However, often both partners have had previous sexual contacts, and there is no guarantee that all of those past partners were not infected. Most cases of HIV transmission in this setting are male to female and result from the man’s past high-risk sexual contacts, including homosexual relations and encounters with prostitutes. Sex tourism to countries with high rates of HIV adds particular risk. Differences in sexual behavior between men and women, combined with the relatively higher efficiency of HIV transmission from male to female, have the consequence that in developed countries only 5 percent of all HIV infections in men are due to unprotected heterosexual intercourse, whereas for women the figure is 33 percent.

Rates of condom use among heterosexual couples vary from study to study, but about 40–60 percent of sexually active individuals report not using condoms. No conclusive data are available in which settings condoms are used. Up to 23 percent of heterosexual men and 35 percent of heterosexual women report having had two or more sexual partners in the past five years, and up to 6 percent of men and 3 percent of women admit to extramarital sex in the past 12 months. Thus, condom use in these settings is of greatest relevance (Johnson et al. 1994, Laumann et al. 1994). Most individuals in monogamous relationships use condoms as a method of contraception rather than as a means of protection against infection.

3.5 Prostitutes

There seems to be a distinction between ‘drug-related’ and ‘professional’ prostitutes. HIV infections are fairly uncommon among professional prostitutes in developed countries; studies report rates of 0.5 percent to 4 percent. Rates of infection among drug-related prostitutes are much higher, with about 30 percent being HIV infected. Behavioral patterns differ between the two groups. Drug-related prostitutes may be forced by either financial need or dependence on a drug supplier to conform to the wishes of their clients, often including sexual intercourse without condoms. This is less the case for professional prostitutes who have more of a choice in their clients and who can insist on using condoms. Rates for unprotected sex among drug-related prostitutes range from 41 percent to 74 percent. In contrast, rates for professional prostitutes range from 20 percent to 50 percent. Rates may be even higher for male prostitutes (Kleiber and Velten 1994).

4. Determinants Of Risk Behavior

Models that attempt to describe and explain HIV risk and protective behavior include the following factors: cultural factors (e.g., ethnic group, social norms), social and environmental factors (e.g., membership in subgroups, knowing HIV-infected individuals), demographic factors (socioeconomic status, marital status), biographic factors (e.g., sexual orientation, attitude toward health), and psychosocial factors (e.g., level of knowledge about STD risk, self-efficacy, attitude toward condoms). Sociological models emphasize the way risk behavior is influenced by social class, educational level and the overall social context.

Social disadvantage often goes hand in hand with lack of opportunities for health maintenance and medical care, and with a higher level of risk-taking behavior. Sexual behavior is imbedded in the mode of living of the individual and is closely tied in with the social environment. Some sociological theories focus on the aspect of communication in intimate relationships and economic factors (e.g., financial dependence). Especially among subgroups such as substance abusers, prostitutes and the socioeconomically disadvantaged, social and economic conditions can be the central factor that controls behavior.

Psychological models focus on determinants of risk behavior that entail processes taking place within the individual. Although a large number of studies have been published since the mid-1980s, and despite a long tradition of research into risk-taking behavior even before the era of AIDS (Yates 1992), there is no comprehensive and sufficiently well-founded theory to explain sexual risk behavior (Bengel 1996). Most significant in the field of sexual risk behavior are the social-psychological models (e.g., Theory of Reasoned Action and Planned Behavior, Theory of Protection Motivation, and the AIDS Risk Reduction Model; see Health Behavior: Psychosocial Theories). For the purpose of this research paper the AIDS Risk Reduction Model is presented because it entails the most direct links to preventive strategies.

It distinguishes between (a) demographic and personality variables, (b) labeling stage variables, (c) commitment stages variables, and (d) enactment stage variables (Catania et al. 1990). Demographic factors such as gender, age, and education, as well as personality factors such as impulsivity or the readiness to take risks contribute little in explaining sexual risk behavior (Sheeran et al. 1999). Also of limited predictive value are labeling stage variables such as knowledge of AIDS, sexual experience, and threat appraisal or risk perception. The assumption is that each individual makes a personal assessment of the risk of infection or disease (perceived vulnerability and perceived severity). A heterosexual, monogamous male, for instance, may perceive the menace of AIDS as a severe health issue, but may feel personally invulnerable or nonsusceptible. However, some individuals who conduct manifest sexual risk behaviors may underestimate their personal risk as compared to others and thereby perform an ‘optimistic bias.’ Many studies have shown significant but tenuous correlations between threat appraisal variables and risk behavior.

Commitment stage variables influence behavior more substantially and include: (a) social influence: perception of social pressure from significant others to

 use or not use a condom and of a sexual partner’s attitude toward condoms; (b) beliefs about condoms: attitudes toward condoms, intentions, and perceived barriers to condom use; (c) self-efficacy: confidence in the ability to protect oneself against HIV; and (d) pregnancy prevention: condom use for contraceptive purposes. Social pressure, self-efficacy, attitudes to- ward condoms, as well as previous use of condoms correlate closely and significantly with HIV protective behavior.

The extent to which protective or risky behavior is displayed also depends on situative and interactive factors, the enacting stage variables. Particularly among casual sexual encounters, lack of immediate condom availability can be the decisive determinant of risk behavior. The nature of the relationship and, in particular, the level of communication about safe sex play a central role in risk behavior. Can the partners communicate about HIV and protective behavior, or are they afraid of offending the partner and jeopardizing what could otherwise be a valued romance?

The significance of the influencing factors above varies, depending on the target behavior (e.g., condom use, sexual practices) and on target group (e.g., homosexuals, adolescents, prostitutes; see, e.g., Flowers et al. 1997). All available theoretical approaches and models assume that HIV-protective behavior is governed by a rational decision process. Emotional and motivational factors, as well as planned behavior and action control, largely have been disregarded in these models and have also been insufficiently researched. After experiencing a risk situation, individuals change both their risk perception and their appraisal of the options available for risk management. Especially when uncertainty or fear about HIV infection is high, cognitive coping (e.g., ‘I know my partner’s friends, so he is not HIV infected’) and behavioral coping (e.g., seeking HIV antibody testing) are deployed.

5. Strategies For Behavioral Change

Reducing the rates of infections with HIV and other sexually transmitted diseases and preventing unwanted pregnancies constitute major tasks for health science and policy. Although sexual risk behavior in most important target groups is difficult to assess, and explanatory models lack empirical validation and are incomplete, preventive programs must be developed and implemented (Kelly 1995). A societal agreement on target groups and on methods used in such prevention programs is essential. The need to prevent the spread of AIDS has triggered lively and controversial discussions in many countries: should the emphasis be on information and personal responsibility, or should regulatory measures be employed to stem the tide of the disease? Controversy has raged among scientists about the ability to influence sexual behavior and the right of the state to intervene in such intimate affairs. There is agreement, however, that sexual risk behavior cannot be regarded as an isolated mode of personal conduct, but must be seen in the context of an individual’s lifestyle and social environment.

Prevention programs promote the use of condoms as the basic method of protection. They promulgate a message of personal responsibility to prevent risk: ‘protect yourself and others.’ AIDS prevention programs in Western European and North American countries have pursued two objectives: (a) to convey basic information on modes of transmission and methods of protection and (b) to motivate the population to assess individual risk and undertake behavioral change if needed. These recommendations start by urging ‘safe sex,’ that is, use of condoms and avoidance of sexual practices in which body fluids are exchanged, in any situation where infection is a potential risk. Individuals are also advised to reduce the number of sexual partners, to avoid anonymous sexual partners and to reduce the use of substances that may result in loss of control.

Prevention programs use mass communicative, personal, and structural measures. Mass communication involves dissemination of information via media such as radio, TV, newspaper, and posters, as well as distribution of brochures and informational leaflets. These media may be intended for all audiences or may be aimed at a specific group. The information is conveyed in simple, concrete, everyday language, describing the modes of transmission and the options available for protection. Personal measures include telephone hotlines, events, and seminars for special target groups, street-working, individual counseling, and information for sex tourists. These person-toperson prevention programs aim at fostering recognition of the problem, improving the level of knowledge, and changing attitudes, intentions, and behaviors of members of particular target groups. Structural measures include the provision of sterile syringes for intravenous drug users, easy access to condoms, and the improvement of the social situation of prostitutes. Preventive measures must be tailored to the lifestyle, environment, and language of each target group given its specific risk behavior pattern and risk of HIV infection. Programs that rely entirely on the generation of fear enhance risk perception but offer no coping alternatives. Specific messages alone, for instance an appeal for condom use, are also often inadequate to bring about (permanent) behavior changes. Communication among sexual partners should be encouraged as one of the crucial target parameters of prevention.

Evaluation of prevention programs has suggested that they have been successful at conveying the most important information about AIDS. In certain sections of the population there are nevertheless uncertainties, irrational assumptions, and false convictions about risk of infection through such activities as kissing or work contacts. The acceptance level of this information varies widely depending on the target group and is lowest among intravenous drug users. As expected, outside of those groups at especially high risk, the greatest fear of infection prevails among persons below the age of 35 and among singles. Only moderate behavioral change has been found among intravenous drug users. Rapid and significant changes in behavior have been found among homosexual males, especially in cities (fewer sexual partners, fewer high-risk sexual practices, increased use of condoms). Yet only a minority practices safe sex all the time, and some of the behavioral changes are relatively unstable. Some experts fear that the messages of preventive campaigns are wearing off and that some individuals are now less concerned about becoming infected than in the past. This may be due to impact of the new antiviral drugs, which have changed the perception of HIV from that of a death sentence to that of a chronic, manageable disease.


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