The fallacy of intimacy: sexual risk behaviour and beliefs about trust and condom use among men who have sex with men in South Africa

The objective of this study is to assess (1) whether beliefs about trust and condom use affect sexual risk behaviour, and (2) if beliefs about trust and condom use impact sexual risk behaviour directly or if this relationship is mediated by other determinants. The Information-Motivation-Behavioural Skills model was used as a framework for the mediation analysis. A diverse cohort of three hundred 18-40 year old men who have sex with men (MSM) residing in Pretoria, South Africa, were recruited and surveyed for this project. Findings indicate that men who report a high frequency of past unprotected anal intercourse are more likely to believe that it is not necessary to use condoms with a trusted or steady partner regardless of their current partnership status. This fallacy of intimacy appears to affect sexual risk behaviour through intentions and attitudes regarding safer sex practices. Based on these findings, we recommend that more attention be given in gaining a better understanding of how beliefs about trust and condom use are formed and how they can be changed among MSM in South Africa.     

Understanding the unprotected sexual behaviors of gay, lesbian, and bisexual youths: an empirical test of the cognitive-environmental model.

The cognitive-environmental model (CEM; M. Fishbein et al., 1991) was used to understand the unprotected sexual behaviors of 156 gay, lesbian, and bisexual youths. Unprotected anal sex among the males was associated directly with poor protection skills (e.g., incorrect use of barrier methods, such as condoms), poor intentions to use barrier methods, and poor norms by sexual partners concerning barrier methods. Furthermore, the association between low self-efficacy and increasing unprotected anal sex was attributed to poor intentions. Direct associations of unprotected oral sex with poor intentions and poor partner norms also emerged, as did an indirect relation between unprotected oral sex and low self-efficacy via poor intentions. These last 3 findings were replicated when examining unprotected oral or vaginal-digital sex among the females. Relations among the CEM factors supported some CEM-theoretical propositions.     

Examining the relationship between use of sexually explicit media and sexual risk behavior in a sample of men who have sex with men in Norway

The purpose of this study was to investigate consumption patterns of gay‐oriented sexually explicit media (SEM) among men who have sex with men (MSM) in Norway, with a particular emphasis on a possible relationship between gay SEM consumption and HIV risk behavior. Participants included 529 MSM living in Norway recruited online to complete a SEM consumption and sexual risk survey. Of the 507 participants who responded to the all items measuring exposure to SEM, 19% reported unprotected anal intercourse with a casual partner (UAI) in last 90 days, and 14% reported having had sero‐discordant UAI. Among those with UAI experience, 23% reported receptive anal intercourse (R‐UAI) and 37% reported insertive anal intercourse (I‐UAI). SEM consumption was found to be significantly associated with sexual risk behaviors. Participants with increased consumption of bareback SEM reported higher odds of UAI and I‐UAI after adjusting for other factors using multivariable statistics. MSM who started using SEM at a later age reported lower odds of UAI and I‐UAI than MSM who started earlier. Future research should aim at understanding how MSM develop and maintain SEM preferences and the relationship between developmental and maintenance factors and HIV sexual risk behavior.     

Impact of combination therapies on HIV risk perceptions and sexual risk among HIV-positive and HIV-negative gay and bisexual men.

The availability of improved HIV treatments may prompt reduced concern about HIV and sexual risk. Gay and bisexual men (N = 554, 17% HIV-positive) completed measures of treatment attitudes, sexual risk, and assumptions regarding the infectiousness of sexual partners. A substantial minority reported reduced HIV concern related to treatment advances. Reduced HIV concern was an independent predictor of sexual risk, particularly among HIV-positive men. In response to hypothetical scenarios describing sex with an HIV-positive partner, participants rated the risk of unprotected sex to be lower if the partner was taking combination treatments and had an undetectable viral load, relative to scenarios with a seropositive partner not taking combination treatments. Prevention efforts must address attitudinal shifts prompted by recent treatment successes, stressing the continued importance of safer sex, and that an undetectable viral load does not eliminate infection risks.     

Commitment to the Relationship,Extradyadic Sex,and AIDS Preventive Behavior1

This study was conducted among 251 heterosexual adults in The Netherlands that included a substantial number of individuals who had had unprotected sex with a new partner. Relationship status and commitment had independent effects upon the willingness to engage in extradyadic sex above and beyond the effects of past extradyadic sex and satisfaction, and commitment was the only psychological predictor of the intention to use condoms in extradyadic sexual contacts. Commitment predicted the willingness to inform the steady partner about one's unsafe extradyadic sex and to protect the steady partner against the possible risk of HIV infection after unsafe extradyadic sex. The implications for AIDS prevention are discussed.     

Transmission risk behaviors in a subset of HIV-positive individuals: The role of narcissistic personality features

Most people living with HIV/AIDS (PLWHA) take steps to protect their sexual partners. However, a minority of PLWHA continue to engage in sexual risk behaviors that might contribute to the transmission of HIV. Psychiatric conditions, including certain pathological traits, are associated with sexual risk behaviors. Research examining the association between narcissistic traits as they relate to HIV transmission risk is limited. In the present study, 303 PLWHA were recruited from an infectious disease clinic and completed questionnaires assessing narcissistic characteristics, substance use, sexual risk behavior, and intentions to use condoms in the future. Narcissistic traits predicted unprotected sex with partners who are HIV-negative or whose HIV status was unknown as well as lower intentions to use condoms, after controlling for demographic factors and substance use. Interventions focused on reducing the transmission of HIV should take into account associations between sexual risk behavior and narcissism.     

Alcohol, sexual arousal, and intentions to use condoms in young men: applying alcohol myopia theory to risky sexual behavior.

Data from 7 studies were aggregated to examine how reported sexual arousal and alcohol intoxication interact to affect attitudes and intentions toward engaging in unprotected sexual intercourse in college-age men (N = 358). When participants were in a sober or placebo condition, their self-reports of sexual arousal had no effect on their responses. When participants were intoxicated, however, those who felt sexually aroused reported more favorable attitudes, thoughts, and intentions toward having unprotected sex than did those who did not feel aroused. These findings support alcohol myopia theory (C. M. Steele & R. A. Josephs, 1990), which states that alcohol intoxication restricts attentional capacity so that people are highly influenced by the most salient cues in their environment. It is suggested that sexual arousal is a powerful internal cue that interacts with alcohol intoxication to enhance attitudes and intentions toward risky sexual behaviors.     

The effects of HIV-related thought suppression on risk behavior: cognitive escape in men who have sex with men.

This study investigated the relationship between suppressing thoughts about HIV risk and several outcomes related to HIV risk, including sexual risk behavior and HIV prevention service use, in men who have sex with men (MSM). Synthesizing the ironic processing theory (D. M. Wegner, 1994) with a cognitive escape paradigm (D. J. McKiman, D. G. Ostrow, & B. Hope, 1996), it was hypothesized that thought suppression might increase risk by leading MSM to "escape" from sexual safety norms and engage in risky sex behaviors and, via a paradoxical process, increase future use of community prevention services. Results from a sample of MSM (N = 709) indicated that thought suppression was positively related to concurrent sexual risk behavior and to future use of prevention services.     

Alcohol use and high-risk sexual behavior among men who have sex with men: the effects of consumption level and partner type.

Alcohol use may increase HIV sexual risk behavior, although findings have varied across study populations and methods. Using event-level data from 1,712 seronegative men who have sex with men, the authors tested the hypothesis that social context would moderate the effect of alcohol consumption on unprotected anal sex (UAS). For encounters involving a primary partner, rates of UAS did not vary as a function of alcohol use. However, consumption of 4 or more drinks tripled the likelihood of UAS for episodes involving a nonprimary partner. Thus, the effects of alcohol vary according to the context in which it is used. Interventions to reduce substance-related risk should be tailored to the demands of maintaining sexual safety with nonprimary partners.     

Self-Esteem, Mood, and Intentions to Use Condoms: When Does Low Self-Esteem Lead to Risky Health Behaviors?

The authors assessed the interactive effects of self-esteem and mood on intentions to engage in unprotected sexual intercourse. Prior research has shown that people with low self-esteem tend to evaluate themselves unfavorably when in a negative mood state, whereas people with high self-esteem are less susceptible to changes in self-evaluation following a negative mood induction. The authors hypothesized that people who engage in negative self-evaluations may be more likely to report intentions to engage in unprotected sexual intercourse. Undergraduate females were randomly assigned to a positive or negative mood induction condition. Consistent with their hypotheses, the authors found that among participants who were in a negative mood state, those with low self-esteem were more likely to report intentions to have sexual intercourse without a condom than were those with high self-esteem. In contrast, among participants in a positive mood, there were no differences between those who were low and high in self-esteem.     

Safe and Unsafe Sexual Intentions and Behavior: The Effects of Norms and Attitudes1

A study of 85 heterosexual men, 85 heterosexual women, and 82 homosexual men was undertaken to examine the variables that influence intentions to engage in different sexual practices and actual sexual behavior. On the basis of Fishbein and Ajzen's (1975) theory of reasoned action, it was predicted that the strength of intentions would be related to whether behavior was in accord with intentions. Consistent with expectations, the strength of intention to engage in six different sexual practices (e. g., vaginal intercourse, anal intercourse, oral sex) and the three strategies that modify the risk of HIV transmission (sex with an exclusive partner, sex wearing a condom, and looking for a new partner) predicted actual behavior. Second, it was proposed that attitudes toward one's sexual practices and norms would be related to intentions to engage in safe sex. To reflect differential levels in the safety of behavioral intentions, five safety intention groups were formed: (a) nonpenetrative sex, (b) penetrative sex in an exclusive relationship with a condom, (c) penetrative sex in an exclusive relationship without a condom, (d) penetrative sex in a nonexclusive relationship with a condom, and (e) penetrative sex in a nonexclusive relationship without a condom. Norms, rather than attitudes, distinguished the five safety intention groups. the groups intending to engage in safe sex (nonpenetrative sex or penetrative sex with a condom) perceived lower levels of social approval for their sexual practices than the noncondom groups. Additional analyses showed that past behavior had a stabilizing effect on the intention-behavior relationship, but only for the nonpenetrative and noncondom safety intention groups.     

Social context,sexual practices,and risks for HIV transmission among men who have sex with men: The south beach health survey

In a population-based sample of 193 men who had sex with men in South Beach, Miami-Dade County, Florida, two indicators of social context—choice of sexual relationships and perceived HIV-infection status—were used to analyze residents who engaged in certain sexual practices with their partners. The vast majority (88.6%) of respondents reported engagement in anal sex during the previous 12 months; 20.2% reported unprotected anal intercourse (UAI) with ejaculation with any partner and 12.4% reported UAI with ejaculation with one or more casual partners. Findings supported the hypothesis that primary partner relationships and perceived HIV status are important variables for understanding engagement in UAI with ejaculation. Men who engaged in such behaviors with casual partners were more likely to have negative attitudes towards condoms, report difficulty communicating desires for safer sex, disagree with the belief that AIDS is fatal, and be intoxicated during anal intercourse. Men who reported engaging in anal intercourse, but who never shared unprotected ejaculations, were most likely to be unknowingly infected with HIV, suggesting that many men may become infected while following what they believe to be “safer sex practices.” In designing effective interventions, public health authorities need to take into account socially embedded risk-negotiating practices.     

The effects of ethnicity and perceived power on women's sexual behavior

To aid development of programs to prevent HIV transmission in women, differences in sexual attitudes and behavior were examined among women who described themselves as dominant in their relationship with a male partner, sharing dominance equally with a male partner, or being dominated by a male partner. Ethnic differences were also examined among these three groups. Results indicated that perceived dominance was a significant predictor of women's personal empowerment (self-efficacy and outcome expectancies) with regard to sexual decision-making in their current relationship and safer sex behaviors. Ethnic differences were found between African American and White women in personal empowerment and safer sex behavior. Perceived dominance did not appear to affect African American and White women differently.     

Relationship commitment and its implications for unprotected sex among impoverished women living in shelters and low-income housing in Los Angeles County.

OBJECTIVE: To examine how relationship commitment among impoverished women is associated with their frequency of unprotected sex. DESIGN: Cross-sectional analyses were conducted on survey data from a probability sample of 445 women initially sampled from shelters and low-income housing in Los Angeles County. MAIN OUTCOME MEASURE: Frequency of unprotected sex in a typical month was derived as the product of 2 items: how often the woman had sex with her partner in a typical month and how often a male condom was used. RESULTS: For both sheltered and housed women, relationship commitment predicted more frequent engagement in unprotected sex with their partner, even after controlling for the type of relationship (primary vs. casual). However, this association could not be accounted for by perceived partner monogamy, ability to refuse unwanted sex, perceived HIV susceptibility, and condom use self-efficacy. Among housed women only, never asking the partner to use a condom partially accounted for more frequent engagement in unprotected sex among women with stronger relationship commitment. CONCLUSION: Results emphasize the importance of relationship commitment issues in HIV prevention interventions with impoverished women, and the need for a better understanding of relationship commitment and its influence on condom use in this population.     

Sexual sensation-seeking and worry about sexually transmitted diseases (STD) and human immunodeficiency virus (HIV) infection among Spanish adolescents

The target of this study is to assess the relationship between sexual sensation-seeking, worry about STD/HIV infection, and risky sexual behaviours among 182 adolescents aged 13-18 years. Results showed that participants who engaged in a wider range of potentially risky behaviours (e.g., sexual experience, higher number of sexual partners in last six months, and the last sexual contact with a casual partner) obtained higher sensation-seeking scores. It was also found that adolescents who engaged in sex with a casual partner in their last sexual contact reported being worried about STD/HIV infection, but adolescents having sex with a steady partner underestimated their risk of STD/HIV infection. These results support the idea that preventive programmes may benefit from including components aimed at teaching adolescents to satisfy their preferences for sexual sensation-seeking through novel and stimulating sexual behaviours involving minimum risk. Similarly, the need to include components aimed at making adolescents become realistically aware of the STD/HIV risk involved in unprotected intercourse with steady love partners is highlighted.     

Single-Session Personalized Cognitive Counseling to Change HIV Risk Behavior Among HIV-Negative Men Who Have Sex With Men: A Two-Part Case Study

Two previous randomized controlled clinical trials have shown the effectiveness of a single-session cognitive intervention, personalized cognitive counseling (PCC), in decreasing HIV risk among men who have sex with men (MSM; Dilley et al., 2002; Dilley et al., 2007). PCC is a counseling technique based on social cognitive theory and the stages of change model and incorporates techniques from cognitive therapy and motivational interviewing. Theoretically, PCC encourages the client to examine his self-justifications, or rationalizations, at the time of intercourse, so he will better understand the thinking behind his decision to have unprotected anal sex. Upon exploring self-justifications that increased risk, we hypothesize that men became more self-aware of the ways in which they made sexual decisions and were thereby better prepared to more realistically assess risk in future sexual situations and make different decisions to decrease their HIV risk.This case study analyzes the PCC intervention of 2 HIV-negative men who have high-risk unprotected sex with men of uncertain HIV status. We present excerpts from the recordings of the interventions to better understand how the technique works. We believe that PCC can be a powerful tool in changing HIV risk behavior and merits more application and study to decrease HIV transmission.     

The singles scene: safe sex practices and attitudes among at-risk heterosexual adults

Heterosexual transmission of HIV accounts for 80% of AIDS cases worldwide and is the main mode of transmission in sub-Saharan Africa and some Asian countries. The extent of heterosexual HIV transmission will likely increase in Western countries. The safe sex practices and attitudes of 58 male and 54 female heterosexuals in Melbourne, Australia, aged 20-40 years, of mean age 27.4 years, were assessed through interview and questionnaire. Study participants were recruited at discotheques and bars catering to single adults. Respondents' attitudes toward safe sex were generally positive, although those attitudes were not always reflected in actual sexual practice. High levels of sexual activity were reported, including high risk behaviors such as unprotected anal sex with casual and regular partners by both men and women. Situational and partner characteristics frustrated the practice of safe sex despite intentions to use condoms. Few men and half of the women explicitly discussed condom use with their sex partners. These findings are similar to those which one would expect from a sample of adolescents.     

Impact of alcohol on sexual decision making: Intentions to have unprotected sex

The impact of alcohol on intentions to have sex with a new partner and the antecedents of intentions were investigated in three studies (N = 139, 60, and 218, respectively). In all three studies, respondents were intoxicated or not intoxicated with alcohol and completed measures based on the Theory of Planned Behaviour in relation to having sex whilst imagining him- or her-self in the scenario. The scenario described unprotected sex between two individuals not in an existing relationship. Consistently across studies, intoxication had a significant effect on intentions for men but not for women. Also consistently across studies, affective attitudes were significantly stronger determinants of intentions for women than for men. Alcohol intoxication consistently moderated the impact of affective attitudes on intentions in women but not men, with greater intoxication associated with stronger impacts (Studies 1, 2, and 3). Implications for understanding the impacts of alcohol intoxication on sexual decision making in men and women are discussed.     

The influence of state and trait affect on HIV risk behaviors: a daily diary study of MSM.

OBJECTIVE: To characterize the influence of state and trait affect on HIV risk behaviors. DESIGN: Men who have sex with men (N = 155) completed reports of trait affect and daily reports of affect and sexual behaviors each night for up to 30 days. MAIN OUTCOME MEASURES: Analyses focused on the role of state and trait positive activation (PA), negative activation (NA), anxious arousal (AA), and sexual activation (SA) on sexual risk taking, operationalized as having a sex partner, a partner-related risk composite, and an HIV risk behavior composite. RESULTS: State SA was positively associated with having a sex partner and HIV risk behaviors; trait SA was positively associated with partner-related risk. State AA was negatively associated with having a sex partner and positively associated with HIV risk behaviors. Trait AA had a negative association with partner-related risk and moderated the effects of state AA. State PA was negatively associated with HIV risk behaviors, and trait PA had a main effect on having a sex partner. NA had no significant trait or state effects. CONCLUSION: These data suggest a role for multiple affective states in sexual risk taking. Models of HIV risk-taking behaviors should be extended to include affective processes.     

Perceived Physical Attractiveness, Sexual History, and Sexual Intentions: An Internet Study

This study was designed to examine the influence a potential date’s physical attractiveness and sexual history has on an individual’s intentions to engage in safer sex. Over 1,200 participants completed an Internet survey. The questionnaire presented a randomized biography and photograph and asked participants to rate their interest in dating and having a sexual relationship with the target. Participants were randomly assigned to one of six conditions based on the target’s physical attractiveness (low vs. high) and sexual experience (low, medium, or high). Results indicated that men reported greater intentions to have sex than women did, and all participants reported greater likelihood of having sex when the potential partner was highly attractive. Participants rated men and more experienced targets as more risky sexual partners, and the level of a target’s sexual experience was directly related to participants’ willingness to discuss sexual risks. Results indicate a continuing need to include discussion of cognitive factors in all HIV prevention efforts.