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Burrow, Tubman, and Gil (2007) "examine[d] patterns of sexual risk behavior and co-occurring general and race/ethnicity-specific risk and protective factors in a community sample of African-American youth (n = 436)" (p. 447) who were between the ages of 18 and 23 years. Youth were clustered according to levels of self-reported sexual risk behavior during the preceding year. Analysis
revealed significant between-cluster differences ... in number of past year sex partners, with members of Cluster 2 (n = 47) reporting significantly higher mean scores than members of Cluster 1 (n = 21), both of which were significantly higher than Cluster 3 (n = 54) and Cluster 4 (n = 246)[; a fifth cluster (n = 42) included all lifetime abstainers]. ... Significant group differences were also detected between each of the four clusters with regard to alcohol use before or during sexual encounters, with Cluster 1 reporting the highest scores, Cluster 3 reporting the second highest scores, followed by Cluster 2 and Cluster 4. With regard to co-occurring sexual behavior and drug use, Cluster 1 reported significantly higher scores than any other cluster, while Cluster 4 reported the lowest scores. (pp. 452-453)
Additionally, "[m]ales were over-represented in clusters reporting the highest numbers of past year sex partners and high levels of substance use before or during sex (i.e., Clusters 1 and 2)" (p. 453). Burrow and colleagues suggest that "[m]embers from each cluster identified in this study could benefit from differentiated HIV/STI prevention efforts targeting unique, cluster-specific vulnerabilities" (p. 459).
Specifically, African-American youth engaging in the highest levels of sexual risk behaviors also were assigned significantly more psychiatric diagnoses. Group comparison using these data revealed that [members of] a small subgroup of ... youth (Cluster 1) were often three or more times more likely to have a history of a diagnosed externalizing disorder, in particular antisocial personality disorder, conduct disorder, and/or a substance use disorder, than were members of the largest cluster reporting the lowest levels of sexual risk behavior (Cluster 4). ...
Youth in Cluster 1 are highly vulnerable to negative sexual health outcomes since their sexual behavior may occur in peer contexts where substance use and other health risk behaviors are normative ... . Prevention strategies for working with these youth should focus on reducing specific psychiatric symptoms. ... In addition, the high levels of co-occurring substance use reported by this cluster must be included as a critical prevention target to reduce risk for STI and HIV exposure and transmission among individuals representative of this cluster ... .
Members of Cluster 2 reported the highest numbers of past year sexual partners ... and are thus at risk for negative sexual health outcomes, despite reporting among the highest rates of protected intercourse. Youth in this cluster reported more than four times the average number of sex partners reported by members of Cluster 3 or 4. Members of Cluster 2 also reported disproportionately high prevalence rates of conduct disorder and antisocial personality disorder, suggesting a potential for callousness toward others. Ostensibly, intervention programs primarily encouraging abstinence may fail to engage youth representative of this subgroup. Instead, identifying more immediate issues and values that are important to these youth may enable researchers to influence meaningful levers for change ... . For example, one could challenge adolescents' views regarding the importance of relationships as contexts for sexual intercourse to encourage reduction of numbers of sexual partners ... .
Cluster 3 was distinguished by the lowest rates of protected intercourse and higher rates of co-occurring alcohol use, foregoing key strategies for reducing STI transmission and unplanned pregnancy ... . Therefore, the relative failure of Cluster 3 to utilize self-protective strategies (in fewer than 40% of sexual episodes) could be addressed through prevention strategies rigorously promoting STI risk reduction behaviors. However, such messages may be undermined by high levels of co-occurring alcohol use by members of Cluster 3 and/or their partners. Thus, additional instruction regarding the disinhibiting influence of alcohol upon adaptive sexual decision making needs to be included in prevention strategies targeting Cluster 3 youth.
Cluster 4, the largest subgroup in the sample, reported the lowest multivariate patterns of sexual risk behaviors, yet its members remain at risk for negative sexual health outcomes. On average, nearly 30% of sexual intercourse episodes reported by Cluster 4 were unprotected. The majority of these young adults also engaged in sexual intercourse with one or more partners during the past year. ... Selective prevention programs that focus intensively on specific issues (e.g., co-occurring substance abuse) may not readily engage members of this subgroup, in particular youth who reported little alcohol or other drug use. Interventions targeting members of this subgroup may be more effective employing a comprehensive universal approach toward reducing risk for HIV transmission. In addition, given the similarity of youth in Cluster 4 to those abstaining from sexual intercourse with regard to levels of psychosocial adjustment, abstinence-oriented messages may be more relevant and viable for these youth. (pp. 457-458)
Continuing this focus on tailoring interventions, investigators in the United Kingdom (Ingledew & Ferguson, 2007) surveyed 200 sexually experienced undergraduates between the ages of 18 and 21 years to test a model in which "personality traits influenced motives for having sex, which influenced self-determination of safer sex, which influenced riskier sexual behaviour" (p. 291). In the final model, "autonomous [i.e., self-determined] motivation for safer sex reduced riskier sexual behaviour, whereas controlled motivation had no effect. Agreeableness reduced riskier behaviour by increasing autonomous motivation for safer sex, an effect mediated by intimacy motive for having sex. Conscientiousness reduced riskier sexual behaviour by increasing autonomous motivation for safer sex. Enhancement motive for having sex increased riskier behaviour" (p. 291). Expanding on these findings, Ingledew and Ferguson observe that
[p]ractising safer sex (as distinct from participating in sex per se) is unlikely to be inherently fulfilling in the first instance, that is to say is unlikely to be truly intrinsically motivated. On the contrary, individuals are likely to be extrinsically motivated for safer sex to begin with. The health promotion objective then becomes to progress along the behavioural regulation continuum, towards more integrated regulation of behaviour. As far as possible, this should happen before individuals are sexually active. Progress along the continuum can be facilitated by autonomy supportive interventions [e.g., motivational interviewing] ..., but some people may need more facilitation than others. It seems that agreeable individuals are inclined to progress along the continuum because they can satisfy their intimacy motive through safer sex. Much existing health promotion emphasises this caring aspect of safer sex. For less agreeable individuals, effective health promotion might emphasise protecting oneself rather than caring for others ... . It seems that conscientious individuals are also inclined to progress along the continuum, perhaps because they can more readily link the safer sex goal with their other goals. Perhaps less conscientious individuals need more help with this aspect of goal setting. For those with a high enhancement motive, health promotion might emphasise ways of increasing the pleasurableness of safer sex. Generally, health promotion should adopt a functionalist perspective ..., in which interventions are tailored to individuals' enduring predilections. (p. 311)
This same perspective may apply equally to affective states. Shrier, Shih, Hacker, and de Moor (2007) explored the affective experience of 67 heterosexually active adolescents (ages 15 to 21 years) following sexual intercourse. "[W]ithin 3-hour intervals during … self-identified waking hours" (p. 357.e3), study participants "used a handheld computer to report current affect and recent sexual intercourse in response to random signals. Participants also completed a report after sexual intercourse" (p. 357.e1). Youth in this study
completed 1385 random and 392 event reports. There were 266 unique coital reports (median 2.6/participant/week); 94% were with a main partner and 49% involved condom use. Youth were more likely to report positive affect and less likely to report negative affect when they were also reporting recent sexual intercourse, as compared to noncoital reports. In multivariate analyses, participants had greater odds of reporting well being and alertness and lower odds of reporting stress and anger following sexual intercourse compared to other times. (p. 357.e1)
According to Shrier and colleagues,
[t]here are at least two important implications of this work for safer sex intervention. First, efforts to modify adolescent sexual behavior need to consider possible affective benefits of sexual intercourse. Awareness that one may feel better after sexual intercourse may motivate or reinforce continued sexual activity[.] ... Safer sex messages may be more appealing and considered more seriously by youth if these messages are more balanced and reflective of adolescents' own experiences in presenting the advantages as well as disadvantages of sexual intercourse and if they discuss alternative means of achieving the affective benefits associated with sexual intercourse. Affectionate sexual behaviors such as hand-holding and kissing have been associated with positive relationship qualities in late adolescent couples ... and thus may offer a means of accomplishing sexual development tasks related to intimacy while minimizing risk.
Second, the affective experience of sexual intercourse is a proximal, personally relevant factor that has been shown to influence risk for STI when it is less positive and more negative ... . Affect following sexual intercourse is also a potentially modifiable risk factor in that STI preventive interventions can aim to reduce adolescents' exposure to coital experiences that may be associated with poorer affect. ... This more targeted approach to modifying adolescent sexual risk may prove more effective than a global abstinence message in promoting healthy sexual development and reducing adverse outcomes ... . (pp. 357.e6-357.e7)
In addition to affect, clinicians may also want to target interpersonal issues experienced by adolescents and young adults. Kershaw et al. (2007) "investigated the influence of attachment avoidance and anxiety3 on sexual beliefs (e.g., condom use beliefs, self-efficacy), behavior (e.g., condom use, multiple partners, unprotected sex with risky partners), and ... STIs ... among [an ethnically diverse sample of] 755 high-risk, young pregnant women (ages 14-25) recruited from urban prenatal clinics" (p. 299). Kershaw and colleagues found that "[a]ttachment anxiety predicted sexual beliefs, condom use, and unprotected sex with risky partners[,] controlling for demographic variables. Sexual beliefs did not mediate the relationship between attachment orientation and sexual behavior. Current relationship with the father of the baby did mediate the effect of attachment anxiety on multiple partners and STIs" (p. 299). According to the investigators, these results
suggest that targeting more general views of relationships (e.g., romantic attachment orientation) may facilitate change in sexual risk beliefs. If relationship conflict is more salient than HIV or STI risk, then increasing an individual's skills to talk about safe[r] sex may not be enough to produce change. If individuals reduce their romantic attachment anxiety, then they may feel more confident in their ability to bring up sensitive topics with their partner without negative consequences or loss of love. Secure attachment is associated with open communication of important issues ... . Therefore, interventions that address issues of attachment may lead individuals to be better able to implement specific HIV-relational skills (e.g., condom communication) within their relationships. (p. 308)
Kershaw and colleagues continue by stressing that
prevention programs are needed that help young couples adjust to parenthood by providing relationship skills (e.g., understanding of attachment avoidant and anxious behavior, intimacy-building, communication, support, positive interactions) as well as HIV-prevention skills. Several interventions have been developed using emotionally focused techniques that expand and change emotional responses, shift partnership interactions, and foster the creation of a secure emotional bond ... . These interventions have been shown to effectively decrease attachment anxiety and avoidance and increase relationship satisfaction and functioning. Intervention programs that integrate these techniques with HIV-prevention may result in more secure attachment, better functioning relationships, and less sexual risk behavior. (p. 309)
Along similar lines, Reich and Rubin (2007) solicited condom scripts (i.e., vignettes in which characters make decisions regarding the use of condoms) from 25 older adolescents who had lost a parent to AIDS but were themselves uninfected. The investigators found that "[i]n equal-influence scripts, an assertive, separating, and powerful female character played opposite an excited male character. In unequal-influence scripts, a permissive, trusting and/or submissive female character was paired with an excited powerful male character. It was in these latter scripts that unprotected sex scenes were likely to occur" (p. 90). To promote condom use among AIDS-bereaved adolescents, Reich and Rubin suggest that these
script prototypes ... provide an empirical base on which to construct discussion group and role-play materials. Exercises such as these would be designed to highlight women's catch-22 position [in safer sex negotiation, i.e., "assumed to be responsible for relationship communication and maintenance ... yet expected to be sexually passive and oriented toward men's pleasure" (p. 91),] to both women and men, stimulating an important – and unscripted – cross-sex discussion leading to script revision. ... [The investigators] argue that teens would energetically relate to intervention messages and activities derived from grounded data, because such interventions would build on what they already implicitly know. (pp. 91-92)
Reich and Rubin further suggest that, "[h]aving identified the key components of equal-influence, safe[r]-sex scripts, a … longer term intervention goal might be to embed them in higher order scripts for casual, dating or committed relationships ... and personal identity ..." (p. 92).
Tolou-Shams, Brown, Gordon, Fernandez, and the Project SHIELD Study Group (2007)
sought to determine if an arrest history could serve as a marker for HIV risk and substance abuse among a community-based sample of high-risk adolescents and young adults. Adolescents (N = 1400; mean age = 18 years) ... in three states (GA, FL and RI) provided baseline data on sexual risk, substance use, attitudes and mental health history. Participants were grouped as arrestees (N = 404) and non-arrestees (N = 996) based on self-reported arrest history. Juvenile arrestees reported more alcohol and drug use, substance use during sex, unprotected sex acts, STI diagnoses, suicide attempts and psychiatric hospitalizations than non-arrestees. (p. 87)
According to Tolou-Shams and colleagues, these findings suggest "that any contact with the legal system, however ... minor, is a marker for increased substance use, sexual risk taking and mental health difficulties. Screening for arrest history may not be routine for many clinical evaluations outside of the legal system; however, these data suggest it may be warranted to effectively identify and respond to the psychosocial and health needs of [these] adolescents and young adults ..." (pp. 89-90). "[A]dolescents with a history of legal offense have a host of mental health needs … that … [must] be addressed. Unprotected sexual activity is a co-occurring risk behavior for these youth and linking youth with an arrest history to brief, HIV prevention interventions may be essential to decreasing the spread of HIV and other STIs" (p. 89).
Finally, on two occasions, approximately 21 months apart, Wiener, Battles, and Wood (2007) interviewed 40 adolescents who acquired HIV perinatally or through a blood transfusion; mean age of the interviewees was 16.6 years at Time 1 and 18.3 years at Time 2. At Time 1, the investigators found that 28% of the interviewees reported that they were sexually active. At Time 2, the percentage increased to 41%. Interestingly, knowledge regarding sexual transmission risk behaviors was relatively low among these interviewees, but increased with age. Nevertheless, both self-efficacy for and reported use of condoms were relatively high, although "almost one fifth of the sexually active sample had either become pregnant or gotten someone pregnant in their lifetime[,] suggest[ing] ... inconsistent condom use" (p. 476). Moreover, "health status as reflected by the level of severe immunosuppression (absolute CD4 counts below 200 cells/mm3) did not preclude adolescents from being sexually active" (p. 476).
These results suggest that by late adolescence, a substantial number of youth with HIV acquisition early in life are sexually active and have moderate to high levels of condom use and moderate to high ... condom[-]use self-efficacy. Importantly, overall condom[-]use self-efficacy was significantly correlated with sexual risk behavior knowledge, establishing an important link between knowledge of HIV sexual transmission risk behaviors and ... [individuals'] confidence in their ability to use condoms, a critical behavior in preventing HIV transmission. In contrast, the lowest self-efficacy scores in the cohort were observed for the ability to totally abstain from sex or abstain from sex even if all their friends are having sex, reinforcing the need for both abstinence and condom-based prevention messages. (p. 476)
According to Wiener and colleagues,
[t]hese results highlight the critical need to provide risk reduction education to adolescents who acquired HIV early in life regardless of whether or not they are currently sexually active and irrespective of their disease status. ... For adolescents who are sexually active or considering becoming sexually active it is important ... to attempt to facilitate both condom use negotiation and diagnosis disclosure to sexual partners so that further sexual transmission of the virus can be avoided. ... This is particularly important among adolescents who may fear the consequences of disclosure of their diagnosis and lack: (a) the skills to discuss such sensitive topics with their partners, (b) confidence in their ability to abstain from sex, or (c) adequate knowledge of safer sex behaviors to prevent further transmission of the virus. This suggests that interventions designed to reduce the risk of sexually transmitting HIV by this population require developmentally appropriate psychological and social approaches that target perceptions of peer influence and emotional well being ... . (pp. 476-477)
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3 "Recent studies suggest that romantic attachment is best conceptualized as two separate continuous underlying dimensions (avoidance and anxiety) rather than discrete attachment styles ... . Individuals vary in their degree of attachment avoidance and anxiety. Attachment avoidance describes feelings of mistrust and [suggests] that one cannot depend on others. Individuals with high levels of avoidance tend not to ask for or give emotional or tangible support and tend to avoid intimacy. This can cause dissatisfaction and conflict among young couples ... . Attachment anxiety describes an unhealthy need to be accepted and loved by partners stemming from a negative view of self. Individuals with high levels of attachment anxiety have poor adjustment, high mental distress, [and] more anger toward partners …[;] engage in controlling and clingy behavior …[;] and have other problem behaviors that may exacerbate relationship conflict ... . Individuals with both high levels of avoidance and high levels of anxiety share characteristics from both dimensions of insecure attachment; they simultaneously have a lack of trust of others (avoidance) but at the same time feel an unhealthy need to be loved and supported (anxiety ...). Secure attachment occurs when levels of both attachment avoidance and anxiety are low. Individuals with secure attachment have fewer relationship problems, better communication, and are less likely to have relationship dissolution than individuals with high levels of attachment avoidance or anxiety ..." (p. 300).
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Summer 2007 Newsletter / Volume 8, Issue 4
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