SEXUAL RISK BEHAVIORS: WHO IS VULNERABLE? AN EXTENSIVE
LITERATURE REVIEW OF SEXUAL RISK PRACTICES AND THE
DEVELOPMENT OF A PAMPHLET FOR AN AT-RISK COMMUNITY
A Dissertation
Presented to the Faculty of
Antioch University Seattle
Seattle, WA
In Partial Fulfillment
of the Requirements of the Degree
Doctor of Psychology
By
Amanda Cohen
June 2009
SEXUAL RISK BEHAVIORS: WHO IS VULNERABLE? AN EXTENSIVE
LITERATURE REVIEW OF SEXUAL RISK PRACTICES AND THE
DEVELOPMENT OF A PAMPHLET FOR AN AT-RISK COMMUNITY
This dissertation, by Amanda Cohen, has
been approved by the committee members signed below
who recommend that it be accepted by the faculty of the
Antioch University Seattle at Seattle, WA
in partial fulfillment of requirements for the degree of
DOCTOR OF PSYCHOLOGY
Clinical Dissertation Committee:
___________________________________
Mary Wieneke, Ph.D.
Chairperson
___________________________________
Alex Suarez, Ph.D.
_____________________________________
Cynde Moya, Ph.D.
_____________________________________Date
ii
© Copy right by Amanda Cohen
All Rights Reserved, 2009
iii
1
SEXUAL RISK BEHAVIORS: WHO IS VULNERABLE? AN EXTENSIVE
LITERATURE REVIEW OF SEXUAL RISK PRACTICES AND THE
DEVELOPMENT OF A PAMPHLET FOR AN AT-RISK COMMUNITY
Abstract
This study examined published research on sexual risk behaviors and the people who
engage in them. Using current and past literature, an extensive review and analysis of
attitudes, beliefs, and causes of sexual risk behaviors was done. Sexual risk behaviors
were defined within the following models: medical, alcohol and drug, societal views, self
definitions, and cultural definitions. The age groups studied were: adolescence (12-17),
young adulthood (18-25), middle adulthood (26-50), and later adulthood (51 and older).
Studies of homosexual men and women and heterosexual women and men were reviewed
as well as a comparison of gender differences. Studies about religion and culture were
reviewed, as well as health, psychological co-morbidity, and substance abuse. And,
finally, a review of interventions used was examined. A critical analysis was done of 164
articles to determine themes, which emerged as gender, age, ethnicity, assessments used,
procedures used, limitations within the articles, and sexual orientation. Finally, an
educational pamphlet was developed to target the largest at-risk group, people between
the ages of 18-25 years. Based on sexual risk behavior literature, this study examines the
impact that risky sexual behaviors have on a person and society, and it also highlights the
importance of accessible education. The electronic version of this dissertation is at
OhioLink ETD Center, www.ohiolink.edu/etd.
Table of Contents
Page
Dedication……………………………………………………………………………….viii
Acknowledgments…………………………………………………………………….….ix
List of Figures………………………………………………………………………….....x
I. Introduction…………………………………………………………………………….1
Purpose of the Study………………………………………………………….......2
II. Background……………………………………………………………………………4
Why is Studying Sexual Risk Behaviors Important to Society? …………………4
Sexual Risk Behaviors Defined……………………………………………….......5
Medical Model……………………………………………………………………6
Alcohol/Drug Model………………………………………………………………8
Societal Model………………………………………………………,……………9
Self Defined Model………………………………………………………………11
Cultural Model…………………………………………………………………...13
Contributors……………………………………………………………………...14
Populations Examined…………………………………………………………...17
iv
Adolescence (12-17)……………………………………………………………17
Young Adulthood/College (18-25)……………………………………………..19
Middle/Emerging Adulthood (26-50)…………………………………………..20
Later Adulthood/Elderly (51 and over)…………………………………………22
Sexuality...............................................................................................................23
Heterosexual Men………………………………………………………………24
Homosexual Men……………………………………………………………….24
Heterosexual Women…………………………………………………………...26
Homosexual Women……………………………………………………………27
A Comparison of Homosexual and Heterosexual Persons……………………..27
Gender …………………………………………………………………………..29
Culture…………………………………………………………………………..30
Religion………………………………………………………………………….30
Ethnicity…………………………………………………………………………31
Comorbid Disorders……………………………………………………………..35
Health……………………………………………………………………………35
Psychological……………………………………………………………………36
v
Substance…..........................................................................................................37
Interventions…………………………………………………………………….38
What was not Studied…………………………………………………………...38
III. Methods......................................................................................................................39
Data Collection…………………………………………………………………39
Summary of Data………………………………………………………………39
Inclusion/Exclusion Criteria…………………………………………………....39
Methodology……………………………………………………………………40
Integration of Articles…………………………………………………………..44
Gender…………………………………………………………………………..44
Age………………………………………………………………………………45
Ethnicity…………………………………………………………………………46
Assessments……………………………………………………………………..47
Procedures……………………………………………………………………….49
Limitations………………………………………………………………………52
Sexual Orientation………………………………………………………………55
Covariates……………………………………………………………………….57
vi
IV. Development of Pamphlet…………………………………………………………59
V. Discussion………………………………………………………………………….63
References……………………………………………………………………………..65
Appendix A - Dissertation Pamphlet: We All Have Things To Say……………….....74
Appendix B - Articles reviewed that met specified criteria…………………………..77
vii
For my mother
Who has always supported me
viii
Acknowledgments
This dissertation could not have been written without the support of Dr. Mary
Wieneke, Ph.D. who not only served as my chair but also encouraged and challenged me
throughout my time at Antioch University. I wish to thank my committee, Dr. Mary
Wieneke, Ph.D., Dr. Alex Suarez, Ph.D. and Dr. Cynde Moya, Ph.D. for their support,
guidance, and good humor throughout this two year process.
Thank you to my friends and family for their unwavering support. Specifically,
Bubba for being a lifelong friend. Sandy Ballatore who has not only edited every paper
for the last five years but who has also become a dear friend. I sincerely want to thank
Kristen Bishop for working with me nearly every day at coffee shops for the last two
years. You never complained when you couldn‘t work because the music was too loud or
were done with your work and always stayed till I was done, and I will always be
appreciative of everything you have done for me. My thanks also goes out to my
boyfriend, Taylor Brown who helped me when I was lost.
Thank you to all my professors and classmates throughout the dissertation classes
for your input and guidance.
Finally, I would like to thank all the researchers who study sexual risk behaviors.
Your work has been an inspiration to me.
ix
List of Figures
Page
1 Gender……………………………………………………………………….45
2 Age………………………………………………………………………......46
3 Ethnicity……………………………………………………………………..47
4 Assessment………………………………………………………………….49
5 Procedures…………………………………………………………………..52
6 Limitations…………………………………………………………………..55
7a Heterosexual…………………………………………………………….....57
7b Homosexual………………………………………………………………..57
8 Covariates…………………………………………………………………...59
x
1
Sexual Risk Behaviors: Who is Vulnerable?
An Extensive Literature Review of Sexual Risk Practices
and the Development of a Pamphlet for an At-Risk Community
Introduction
Dr. Philippe Ricord was the first doctor to study venereal disease, primarily
syphilis and gonorrhea in women (Dracobly, 2004). Dr. Ricord noticed the multiple ways
in which a woman can contact venereal diseases, and he began investigating the ways in
which oral and anal sex could contribute to the transmission of syphilis and gonorrhea.
Although Dr. Ricord‘s ―cure‖ of mercury did not work, his understanding that many
factors contributed to the transmission and infection of syphilis and gonorrhea made him
a pioneer in the field of venereal research.
Today in the United States, every nine and a half minutes, a person is infected
with HIV (cdc.gov), and the reported lifetime STD rates range from 12% to 25% (Abbey,
Parkhill, Buck, & Saenz, 2007). In a 2008 study done by Mueller, Gavin, and Kulkarin,
93% of Americans supported the presentation of sex education in some form. However,
research has shown that although abstinence-only programs have increased, they have
been ineffective. The authors noted that early education can help prevent sexually risky
behaviors later in life. Teaching people ―how to say no‖ and providing education about
birth control and STDs can help postpone sexual intercourse and increase the likelihood
of safer sex. This paper focuses on sexual risk behaviors among multiple ages, sexes,
ethnicities, religions, and sexual orientations in the hope of presenting the people who are
most at risk. Also, it discusses education that promotes safe-sex practices that reduce risk
2
Purpose of the Study
The purpose of this study is to develop a better understanding of sexual risk
behaviors by examining current and past research, community definitions, as well as
attitudes and beliefs that have emerged about sexual risk behaviors. By collecting and
analyzing data across the field of human sexuality and sexual risk behaviors, a more
comprehensive picture of persons who are engaging in sexual risk behaviors is revealed.
Once identified, it is possible to look further into the problem and ask why these groups
of people are engaging in these risk behaviors and what can be done in terms of
intervention to help prevent them from making these behaviors habitual? The purpose of
this study is to bridge a gap in the research by comprehensively examining articles on
sexual risk behaviors in hopes of learning what happens to people who engage in sexual
risk behaviors. Also, this project will result in a pamphlet geared toward persons 18-25
years old who have been identified as one of the highest at-risk communities.
Understanding the prevalence of those who engage in sexual risk behaviors can
help researchers and the health care communities educate people on risky behavior in
hopes of decreasing risky sexual practices among all persons. Researchers are not alone
in not having done a sufficient job of educating the at-risk community about the outcome
of sexual risk behaviors, what happens after the studies are done, and how the research
has affected the people. Because of limitations in the research, it is hard to hypothesize
about the long-term effects of interventions for sexual risk behaviors.
Longitudinal studies have not comprehensively investigated sexual risk behaviors
across age ranges. Therefore, it is important to study the gaps in the literature and locate
3
the age groups or demographic groups where research is lacking. No prospective studies
related to sexual risk behaviors were found to follow a group throughout their lives.
Studies that have shown persons to engage in risky behavior at age 15 have not
longitudinally studied what happens to those persons when they are 25, 35, 45, or 55
years of age. To date, the research has focused on limited demographic variables, such as
18-25 year olds enrolled in college or persons over the age of 50 in nursing home
settings.
4
Background
Why is Studying Sexual Risk Behaviors Important to Society?
Miller et al. (2004) stated that although sexual behavior has long been a focus of
research investigation, research examining sexual risk behaviors and how they correlate
with family, peer, and community has been lacking. Because sexuality is an important
aspect of one‘s life and can alter an individual‘s familial, societal, and cultural
environment as a whole (Askun & Ataca, 2007), studying risky sexual behaviors is
important because they can threaten both physical well-being and social interactions.
Many attitudes, behaviors, and concepts with regard to sex and sexuality are socially
constructed (Askun & Ataca, 2007). These researchers noted that cultural sexual attitudes
may include the general beliefs of a particular culture, personal decisions about when
sexual intercourse is permissible, as well as individual attitudes concerning appropriate
and inappropriate sexual behaviors.
According to Abbey, Parkhill, Buck, and Saenz (2007), approximately 19 million
sexually transmitted diseases are diagnosed annually within the United States. Of those,
almost half are contracted by people between the ages of 15 and 24. These researchers
report that at least half of all HIV patients are age 25 years old and younger, and that the
rates of transmission through heterosexual intercourse are increasing, particularly for
young women. According to Quandango, Sly, Harrison, Eberstein, and Soler (1998),
experts in public health, education, and risk-intervention have generally all agreed that
women ―need to assume a greater responsibility‖ for their sexual behaviors. However,
this assumption depends on the women increasing communication with their partners and
5
discussing sexually related issues. Understanding the motives of people who engage in
risky sexual behaviors may help provide insight into understanding the factors that
contribute to and maintain an individual‘s engagement in these behaviors (Miller et al.
2004).
Papaharitou et al. (2008) studied men and women over the age of 60 who were
sexually active on an occasional or regular basis. They found that contrary to the notion
that elderly individuals are not sexually active, they, in fact, maintain sexual interest and
pleasure and their sexual interest/pleasure is associated with a range of personal,
socioeconomic, and interpersonal factors. Winningham (2006) reported that
approximately one in six people living with AIDS is over the age of 50. Papaharitou et al.
(2008) does not address the importance of educating individuals in this age range; they
reported only that the people are still engaging in sex. Winningham (2006) reported that
persons in this age group are one-sixth less likely to use a condom during sex than are
younger adults. Education is needed within this age group about risk behaviors.
Sexual Risk Behaviors Defined
Taking risks and experimenting with a variety of new activities can be considered
healthy, depending on the activity. However, when ―…the need for varied, novel, and
complex situations and experiences and the willingness to take physical and social risk
for the sake of the experiences…‖(Gullette & Lyons, 2006, p. 24) becomes risky to
individuals and those around them, they are no longer engaging in healthy exploration of
new activities. The definitions for sexual risk behaviors will be a broad extension of the
literature. I have blended many different definitions from published research and defined
6
various areas to further explain and explore the definition of sexual risk behaviors as an
overall construct. The five sections that emerged are (a) the medical model, (b) the
alcohol/drug model, (c) the societal model, (d) the self-report model, and (e) the cultural
model. No research articles were found that used all five definitions as stated to define
sexual risk behaviors.
Medical Model
Sexual risk behaviors have often been defined within the medical model as being
restricted primarily to the act of intercourse and lack of condom use. An example of this
definition is found in Huebner and Howell‘s (2003) discussion of sexual risk behaviors as
―…a history of sexual intercourse involving either multiple partners and/or no condom
use‖ (p. 78). Coley, Medeiros, and Schindler‘s (2008) definition did not extend much
beyond Huebner and Howell‘s, in that it added lack of reliable birth control and increased
susceptibility to STDs, only.
Within the medical model, sexual risk behaviors are defined as having
unprotected intercourse (vaginal and/or anal) that places a person at risk for a sexually
transmitted disease (STD), HIV/AIDS or unintended pregnancy. Additionally, risk
behavior is that engaged in by persons who knowingly have an STD or HIV/AIDS and
participate in unprotected sex, which ultimately endangers both the individual and their
partner (Vesely et al. (2004), Harris et al. (2006). Having multiple sexual partners or
unprotected sexual intercourse outside of a mutual monogamous relationship can also
pose a risk to both individuals for contracting an STD (Gullette & Lyons, 2006).
7
Kef and Bos (2006) stressed the importance of educating persons who have health
problems and disabilities. The authors noted that while dating may occur less among
people with physical disabilities, they are still sexually active and may have been poorly
informed about general sex knowledge. In addition, Kaeser (1996) reported that
individuals with severe or profound mental retardation (IQ scores between 31 and 50)
were engaging in genital touching and intercourse but with little or no knowledge of safe
sex and protection.
Within the mental illness arena, people with bipolar disorder who are exhibiting
manic symptoms, such as increased energy, grandiosity, impulsivity, and poor judgment,
may be more likely to engage in risky behaviors. Meade, Graff, Griffin, and Weiss (2008)
reported that some mentally ill individuals engage in sexual risk behaviors that could put
them at risk for HIV/AIDS, such as unprotected sex, multiple partners, and trading sex.
The authors further stated that persons with mood disorders are more likely to be sexually
risky than those with psychotic disorders, as persons who are manic may have increased
sexual thoughts, sexual desire, and/or sexual activity.
Hallfors et al. (2005) reported on the importance of screening for depression
among young females, as depression may be a contributor to acting sexually risky. The
authors noted that women who engage in high-risk behaviors and are also depressed
should seek treatment for both depression and sexual decision making. Von Sadovszky,
Vahey, McKinney, and Keller (2006) reported that while people go into encounters with
positive emotions if they are planned, over half of the participants in their study (53%)
8
had negative or mixed emotions following an unplanned sexual encounter that was
considered risky. In turn, this impulsive behavior could add to their depression.
Alcohol/Drug Model
Expanding the definition are those people under the influence of alcohol and/or
drugs. A person under the influence may have casual sex with unknown partners and fail
to use a condom, and potentially engage in other risky sexual practices (Dew, Elifson,
Sterk, & 2007). Schafer, Blanchard, and Fals-Stewart (1994) hypothesized that those
under the influence of a substance may have clouded judgment, lower inhibitions, and
decreasing sensitivity toward pain during intercourse, which may lead to an infection and
an STD.
In 2001, Sherman and Latkin reported that for those under the influence of drugs
while engaging in unprotected sexual intercourse, the rates of HIV infection had not
decreased extensively when compared to injection-related risk behaviors. In fact, in the
wake of the HIV/AIDS epidemic, current researchers have focused extensively on the
behavioral risk factors associated with substance abuse and HIV transmission (Schafer,
Blanchard, & Fals-Stewart, 1994). Hendershot, Stoner, George, and Norri (2007) detailed
a model whereby sensation-seeking individuals under the influence of substances were
more likely to engage in risky behavior that could put them at risk for HIV/AIDS and
STDs. Within the model, the researchers reported that two personality types emerged: (a)
sexual sensation seeking, which was defined as ―the propensity to attain optimal levels of
sexual excitement and to engage in novel sexual experiences‖ and (b) sexual
9
compulsivity, which was defined as ―a propensity to experience sexual disinhibition and
under-controlled sexual impulses and behaviors‖ (p. 365).
Among adolescents, high risk sexual behaviors and their associations with drugs
and alcohol abuse have caused a large concern within the health care system (Wagner,
2001). Wagner (2001) drew upon Zuckerman‘s (1979) model of sensation seeking and
reported that high school and college students who are high sensation seekers are more
likely to engage in risky sexual behaviors, use drug/alcohol, drive recklessly, steal and
engage in vandalism (p. 116). The author adds that the choice to engage in such
behaviors was within an individual‘s personal control. Wagner (2001) claimed that
elements of self control, if studied, could be used in prevention and treatment protocols to
help eliminate unwanted behaviors.
When looking at men who have sex with men (MSM), Torres and Gore-Felton
(2007) report that associations exist between sexual risk behaviors and substance abuse,
number of partners, and lack of social support. The authors also noted that anxiety and
depression influence risk behaviors and, although few studies have examined the
correlation between loneliness and HIV-related risk behaviors among this population,
they hypothesized that feelings of loneliness may lead to the use of alcohol and drugs,
multiple partners, and engaging in anonymous sex. All of these activities place them at
risk for HIV (p. 64).
Societal Model
Furthering the definition, Miller et al. (2004) explained the importance of the cost
of these behaviors to both the individual and society as a whole. Persons who are
10
engaging in risky sexual behavior and having unprotected sex may consequently have to
deal with unplanned pregnancy or abortion. An unplanned pregnancy, Miller et al. (2004)
suggested, could impact the individual‘s academic success and employment, as well as
other aspects of their life (p. 1612).
Globally, adolescents may be faced with many problems with regard to sexual
risk behaviors and STDs, unwanted pregnancy, and substance abuse. For those who live
at the poverty level, obtaining knowledge about resources and education may be difficult
and, they may be more likely to unknowingly engage in such high-risk behaviors
(Gutierrez, Bertozzi, Conde-Glez, & Sanchez-Aleman, 2006). When correlating
sociodemographic factors with sexual risk behaviors, Peterson (2006) found that the
daughters of single, African American mothers were more likely to engage in sexual risk
behaviors than were daughters of single Caucasian mothers. Peterson (2006) highlighted
that of the 100 mothers studied, African American mothers were more likely than
Caucasian mothers to report living in poverty and having a lower level of education. Both
factors were related to increases in sexual risk behaviors among adolescent girls.
According to Sandfort, Orr, Hirsch, and Santelli (2008), the rates of adolescent
pregnancy may have declined over recent years in the United States, but adolescents are
still responsible for the highest population of females with unwanted pregnancies. The
authors continued to note that while the incidence of STDs has decreased, adolescents
continue to be among the highest of those infected. The authors‘ concern regarding this
population‘s at-risk status was attributed to the promotion of abstinence-only programs.
They believed that the ―…promotion of sexual abstinence until marriage has become a
11
cornerstone of U.S. domestic and global practices‖ (p.155). The authors noted that the
federal government guidelines regarding abstinence-only programs focus solely on
knowledge of social, psychological, and health gains that can result when people abstain
from sex (Sandfort, Orr, Hirsch, & Santelli, 2008). The authors noted that the theory
behind abstinence-only programs was to help avoid STDs and unintended pregnancies.
They found, however, that abstinence-only programs increased health risks. They
suggested that education geared toward health and motivation would be more helpful in
reducing short and long term health risk among adolescents.
Finding results that were contrary to those of American programs, Herlitz and
Ramstedt (2005) reported on sex education programs in Sweden that were set into place
―long before the AIDS epidemic…‖ (p. 220). The authors noted that Swedish sex
education programs begin in primary school where students are taught the basic
reproduction system. As students advance, they are taught ―age-appropriate‖ information
regarding contraception, STDs and HIV/AIDS. They learn where to locate regional
health care clinics that they can visit if they have questions. One of the findings the
authors reported was that sexually active adolescents between the ages of 16-17 were
more likely to use condoms than were those who were a few years older, a behavior that
is markedly different from that of American adolescents.
Self-defined Model
When defining sexual risk behaviors, it is imperative to understand that while the
definition I am using is research-based, it is ultimately based on self-definition or self
12
report (Scandell et al., 2003). Therefore, the definition has emerged from the
participants‘ own reported behaviors.
Schrimshaw et al. (2006) reported that in a recent review of the literature
regarding the reliability of self-reporting measures for sexual risk behaviors, only 15
articles were found. Scandell et al. (2003) reported that high sexual risk behaviors are
underreported and that unprotected sex is over-reported. This happens mainly in face-toface interviews, which is ―a commonly used methodology in clinical and research
settings‖ (p. 120).
A difference of opinion appears in the research regarding the optimal
methodology for conducting interviews. Some researchers have chosen to do them
online, while others have chosen to do phone interviews and others conduct them in
person. All of these interview methods can influence the accuracy of self reporting.
Nicolosi et al. (2006) studied sexual problems among the elderly using phone
questionnaires. The participants were asked if they had had sexual intercourse over the
last year and, if so, had they experienced sexual problems that were itemized on a
provided list. The authors noted that they chose this methodology because they wanted to
avoid the embarrassment that could happen during face-to-face interviews.
Gullette and Lyons (2006) utilized the Internet and sent emails to study college
students between the ages of 18-43. Alcohol intake and risk behaviors were researched.
The researchers acknowledged that using an online survey relied solely on self reporting;
therefore, students might have over-reported or under-reported their behaviors. The
authors also noted that a limitation inherent in this method was that students could
13
―…inaccurately recall sexual activities, such as using or not using a condom‖ (p. 30).
Scandell et al. (2003) reported that college students tended to misrepresent their sexual
histories when asked about them in order to appear less risky. Utilizing a self-report
measure of sexual risk behaviors, the researchers found that one third of students who
had previously tested positive for an STD did not disclose that test result to their partners.
In reviewing this research it is also important to distinguish that sexual risk
behaviors may be different among each population. For example, unprotected sex within
a monogamous relationship, such as marriage, may not be considered risky. However,
unprotected sex with a stranger could be considered risky. Another consideration that
should be made is that not every person who has sex while intoxicated is acting in a risky
manner. However, the distinction is made by determining which behaviors the person
engages in while intoxicated. For example, a person whose blood alcohol level is below
the legal limit could engage in sexual intercourse with a stranger safely, by using a
condom, which would be considered less risky than if that person had unprotected sex
with a stranger.
Cultural Model
Quadagno et al. (1998) reported that African American women are less likely than
American or Hispanic women to engage in sexual acts other than vaginal intercourse.
Caucasian women are approximately 30% more likely to receive and give oral sex than
African American women (Quadagno et al., 1998). The researchers stated that they
believe that ethnic backgrounds do not differ in the incidence of vaginal intercourse, but
anal intercourse appears to be higher among heterosexual Hispanic women.
14
Quadagno et al. (1998) explained that one of the reasons for this difference could
be due to culture and the differences in the ways that people in Hispanic culture reinforce
gender and sex versus the ways that people in European American culture do. When
studying Hispanic women and men, Quadagno et al. studied men and women in America
and therefore the sample consisted of persons who resided in America but could have
been born anywhere. Quadagno et al. (1998) reported that within Hispanic culture, the
value of “machismo” may contribute to the dichotomy among the genders. Given this,
women are typically not allowed to discuss relationships and ―sex is considered a private
issue….‖ (Quadagno et al., 1998, p. 58). The authors noted that women learn about sex
from their husbands and, therefore, their knowledge can be very limited. For example,
Quadagno et al. (1998) reported that Hispanic women are not allowed to bring up
subjects such as sexual behaviors or condom use. In situations such as these, culture plays
a vital part in sexual risk behaviors. A woman may unintentionally engage in sexual risk
behaviors because she does not know differently. When educating on sexual risk
behaviors and health in such situations, culture should be an integral factor.
Contributors
Contributors are defined as anything that may cause or be involved in a person
engaging in sexual risk behaviors. Unlike drugs and alcohol as contributors, a person‘s
experiences play a part and people may not be fully aware of the impact these
experiences have on them. For example, Oswalt, Cameron, and Koob (2005) discussed
the importance of anticipated regret with regard to sexual risk behaviors. The authors
studied anticipated regret with college students and defined it as mainly having regret
15
after one‘s first sexual experience. The researchers discussed the fact that if an individual
engaged in a behavior that they regretted, they might have a higher emotional intensity
with regard to the situation. Conversely, researchers stated that those who have less
experience sexually and have not engaged in other risky activities, reported lower
anticipated regret toward engaging in high risk behaviors, such as having unprotected sex
(Oswalt, Cameron, & Koob, 2005).
Oswalt, Cameron, and Koob (2005) researched people from their early 20s to late
70s and asked them to reflect on sexual experiences or lack thereof with regard to
premarital sex. The researchers found that about 40% had some regret about premarital
sex, whereas only 8% regretted that they did not have premarital sex. When examined by
gender, the subjects revealed that twice as many women regretted having premarital sex,
whereas twice as many men regretted not having premarital sex.
When expanding this theory to adolescents, Serovich and Greene (1997) reported
that predictors of behaviors can be seen by determining the influences on ―voluntary‖
behavior. The researchers described a person‘s intent to engage in a behavior as being
their attitude about the behavior as a whole and their perceptions learned from others, as
well as whether they thought they should or should not engage in the risky behavior.
Shrier et al. (1996) summed up Schneider and Morris‘ (1991) research by stating
that individuals who engage in a multitude of risky behaviors may form ―risk behavior
syndrome‖ (p. 378). Individuals experiencing this syndrome are at risk for serious
repercussion, not only physical but legal. In addition, Shrier (1996) reported that the
earlier the onset of the problem behaviors, the more severe the behaviors became.
16
Rye and Meaney, (2007) reviewed the importance of the pursuit of sexual
pleasure as a primary motive for engaging in sexual activity. The researchers stated that
―uncommon [sexual practices] does not equal pathological‖ (Rye & Meaney, 2007, p.
38). The authors noted that most sexual behaviors can be found on a continuum from
healthy to pathological. When the sexual pleasure has become a primary motivation and
the individual does not account for the safety of themselves and their partner, then they
may be engaging in risky sexual practices.
In considering the cultural influences within the United States, Serovich and
Greene (1997) noted that in the case of HIV/AIDS, they believed that people‘s attitudes
toward risky behaviors as well as the collective attitude prevalent in their societies were
important and could influence an individual‘s actions. For instance, education given to
adolescents surrounding STDs is generally geared toward abstinence, reduction of sexual
activity, and number of partners. This three-part focus has neglected a critical component
of education: understanding the attitudes that adolescents have toward risky behaviors.
Serovich and Greene (1997) believed that it is critical to understand adolescents‘ attitudes
toward preventive measures, such as using condoms to help prevent HIV/AIDS. Because
many adolescents get their information not only from peers but also from school, Somers
and Gizzi (2001) argued that if students became isolated from school, they were more
likely to engage in risky behaviors. Therefore, it is important to keep adolescents
involved with their environments.
Schneider and Morris (1991) associated risky sexual behaviors with not using a
seat belt, physical inactivity, and failure to use helmets or sunscreen. Schneider and
17
Morris (1991) also noted that problem behaviors may contribute to risky behaviors. For
example, those who are at risk of being arrested are more likely to engage in severe risky
behaviors. Oswalt, Cameron and Koob (2005) continued this relationship by adding that
there is an association between sexual risk behaviors and smoking cigarettes and skipping
school.
Populations Examined
I am exploring the demographics of participants engaging in sexual risk
behaviors. Primarily, the questions include: What populations are at highest risk? Which
is at the highest risk? What additional factors contribute to their actions and make them
risky? Within this inquiry, the age groups examined are: adolescence (ages 12-17),
college age or young adulthood (18-25), middle adulthood (ages 25-50), later adulthood,
and elderly (ages 51 and over). Studying a broad range of ages allows better
understanding of who is engaging in sexual risk behavior. Within this section, age is the
primary focus, and any possible contributors that may influence an individual to engage
in risk behaviors are included as well.
Adolescence (12-17)
Adolescence is a time of exploration that can involve sexual experimentation
when people are not necessarily emotionally ready for the responsibilities that come with
being sexually active. Morrison-Beedy, Carey, Feng, and Tu (2008) reported that almost
one half of sexually active persons will acquire an STD by the age of 25, and those in
their late adolescence are particularly vulnerable to Chlamydia and Gonorrhea. The
authors reported that with the alarming rates of HIV/AIDs rising in today‘s younger adult
18
population, it is assumed that they were infected when they were in their adolescence,
since the time frame for diagnosis can be 5-10 years.
Lohman and Billings (2008) studied adolescent boys who engaged in sex from the
age of 12 to 15 years old. The authors found that boys who were sexually active at that
young age were more likely to have academic problems, have an increase of problems at
school as well as substance abuse problems. The authors noted that adolescents having
sex at such a young age could not only have long term affects on their health, but also
could cause societal problems, such as unintended pregnancy.
Rose et al. (2005) reported that contraceptive use is very low among the
adolescent population, and with the rise of early sexual activity, the result is a greater risk
for both pregnancy and STDs. The researchers noted that when compared with older
adolescents or people in their 20s, younger adolescents who decide to carry a infant to
term have higher rates of premature delivery and lower birth rates. William, Connolly,
and Cribbie (2008) stated that because one of the highest risks for early adolescents who
are engaging in sexual activities is pregnancy—which can lead to both psychological and
health risk for the adolescent— substantial efforts need to be made to intervene early on.
The consumption of drugs and alcohol within the population has contributed
significantly to people engaging in risky sexual behavior (McHale & Newell, 1997).
McHale and Newell (1997) reported that 50% of the participants studied engaged in
unprotected sexual intercourse while under the influence. Sex education is vital for this
population. Muller et al. (2008) reported that once people become sexually active, sex
19
education may have little impact within the age group in stopping sexual intercourse, but
it can help with contraception use and condoms.
Young Adulthood/College (18-25)
People in college have been identified as the most at risk for engaging in sexually
risky behaviors. Approximately 80-90% of college students report being sexually active
and only one third report using condoms on a regular basis (Abbey, Parkhill, Buck &
Saenz, 2007 and Eisenberg, 2001). Both Abbey, Parkhill, Buck, and Saenz (2007) and
Eisenberg (2001) reported that college students are likely to have multiple sexual
partners, averaging six or more partners. Moore and Davidson (2006) reported that even
with a flooding of educational material regarding safe sex practices, some college women
have not changed their sexual practices. The authors noted that ―…being well-informed
about sexual risk does not necessarily result in behavioral change‖ (p. 577). Moore and
Davidson (2006) found that women wanted to have education about sexual health and
risk behaviors that was more personalized to them as individuals, such as, personalized
information about sexuality, reproduction, contraceptives, decision making, assertiveness
and communication skills examples, as well as how to apply them individually within
situations.
According to Gullette and Lyons (2006), college students may engage in
unprotected intercourse, have multiple sex partners, attend ―wild‖ parties, seek ―novel‖
social experiences (i.e., join Greek organizations or experiment with drugs), and consume
―large‖ amounts of liquor. The researchers also stated that women who engage in sexual
risk behaviors have more negative attitudes toward using condoms, possess lower self
20
esteem, and use illegal drugs on average more than do women with higher self esteem
(Gullette & Lyons, 2006).
Randolph et al., (2007) examined sexual pleasure and condom use among college
students and found that both men and women reported that using condoms significantly
reduced sexual pleasure. The researchers reported that men valued unprotected sex more
and believed that using a condom reduced pleasure more often than did women.
Interestingly enough, Flannery, Ellingson, Votaw, and Schaefer (2003) found that
although college students are more likely to have multiple sex partners and not
consistently use condoms ―…they are more likely to have higher levels of sexual selfefficacy and use a condom if a partner requests it, and both practices are associated with
lower risk of HIV infection‖ (p. 228). It may be likely that Chin‘s (1999) theory about
women‘s schema and possible lack of strength which could lead to a woman not being
comfortable discussing safe sex practices with her partner, can help illustrate the
inconsistencies. Hypothetically, if college students felt more self efficacious about their
own sexual ability, they might be more comfortable asking their partner to use a condom,
in which case their partner could agree. However, it is also likely that students may lack
self efficacy and are not comfortable asking about condom use.
Middle/Emerging Adulthood (26-50)
Research on middle or emerging adulthood is defined for the purpose of this
paper as individuals between the ages of 26 to 50 years old. There is sparse research
among this population, therefore any conclusions made of the emerging adulthood
individuals sexual risk practices should be done with caution. Kaestle and Halpern,
21
(2007) researched this age population and examined what should be considered risky
sexual behaviors within the context of a ―loving relationship.‖ The authors noted the
importance of examining the length of the relationship before defining their activities as
risky. In the early stages of emerging adulthood, persons may be newly out of college,
and the way in which they enter and view a relationship is different from the way they
viewed relationships when they were in college. Kaestle and Halpern, (2007) stated that
the emotional development for emerging adulthood relationships should occur within the
first three to four months. During this time, emerging adults date and may fall in love and
this time is often referred to as the ―honeymoon‖ phase. Kaestle and Halpern, (2007)
stated that sexual activity during this time is novel and, therefore, the couple could
engage in risky behaviors at this time. The authors found that ―….relationships of less
than one month‘s duration include more frequent fellatio but less frequent cunnilingus
than longer term dating relationships‖ (p. 134).
Kaestle and Halpern, (2007) noted that additional research is needed in a broad
range of areas because current literature on oral and anal sexual practices is limited. The
researchers found that of 3,000 individuals surveyed by the National Health and Social
Life Survey, 85% had engaged in vaginal sex in the past year, 69% of women had
performed fellatio while 74% of men reported receiving fellatio, 75% of women reported
receiving cunnilingus and 72% of men reported giving it and 16% of both men and
women reported having anal sex. (p. 135).
When reporting on working with this population, Risen and Altof (1990) said that
it is important to work with couples, because this is the time in life when most adults
22
choose a committed partner and could be unknowingly engaging in sexually risky
behavior together. Furthermore, showing the couple how to have open dialogue about
their previous sexual experiences is vital, because STDs can go undetected for years.
Later Adulthood/Elderly (51 and over)
Research on later adulthood or the elderly populations (persons over the age of
51) has shown that people in this group possess a desire to be sexually active. There is a
lack of research among this population therefore any conclusions about the elderly sexual
risk practices should be done with caution Although labels such as ―dirty old man ―and
―asexual‖ can often be associated with this population, when individuals want to continue
to be sexually active, both men and women continued to report their desire to be sexually
active as they aged (Nagartnam & Gayagay, 2002; Nicolosi et al., 2006). In the elderly
population, specific sexual dysfunctions arise that may interfere sexual activity. Nicolosi
et al., 2006, examined sexual activity and the prevalence of sexual dysfunctions among
the elderly and found that 11% of men studied reported having delayed ejaculation and
among women 13% reported inability to reach an orgasm. In addition, sexual functioning
can be affected by health concerns which typically increase with age. For example, with
someone who experiences a stroke, sexual behaviors may become very different from
those experienced prior to the stroke, and they may be seen as unusual or inappropriate
(Nagartnam & Gayagay, 2002).
Research has continued to show that unprotected sexual contact is the most
reported form of HIV transmission within the elderly community, and older adults are
one-sixth less likely to use a condom as compared to the younger generations
23
(Winningham, 2006). Physiological changes that occur as women age contribute to the
risk of being infected with HIV/AIDS. Women may experience a ―…decrease in vaginal
lubrication and estrogen deficiencies, which cause thinning of the vaginal
walls…[and]…these physiological changes allow for microscopic tearing during sexual
penetration and, therefore, provide a direct route for HIV transmission‖ (Winningham,
2006, p.1) Pratt and Schmall (1989) detailed the importance of educating the elderly
about sexuality. In addition, Pratt and Schmall (1989) reported that education should be
focused on all aspects of sexuality, such as touch, intimacy, body image, and affection,
instead of the focus being mainly on genital sex. Also focus should be on safer sex
practices.
Sexuality
When examining sexuality, I focused on heterosexual and homosexual
populations separately and in relation to each other with respect to risky sexual behavior.
Dew, Elifson, Sterk (2007) report the importance of studying homosexuality and
heterosexuality separately. The authors found that both groups engaged in sexual
behaviors that put them at risk for contracting HIV and hepatitis C, in addition to other
STDs, but that homosexual men engaged in behaviors that put them at risk at an only
slightly higher rate. Often when researchers examine the thinking behind sexual risk
behaviors among men, homosexual men are thought to engage in more risky behavior.
However, the Dew, Elifson, Sterk‘s (2007) article highlighted the risks that both
homosexual and heterosexual men take.
24
Heterosexual Men
When researching heterosexual male college students, Eisenberg (2001) found
that older students and non-Caucasian students were more likely to report having multiple
sex partners over the last 30 days. Consistent with the research, the Eisenberg study
(2001) found that people with more partners reported less consistency with condom use.
Interestingly enough, Eisenberg (2001) found that those who did report using a condom
consistently, were under the age of 23. Those who were 23 years or older reported not
only using condoms less consistently but also reported that they were engaging in the
same-sex sexual practices (Eisenberg, 2001).
Catania, Coates, and Kegeles (1994) found that men who communicated about
sexual health were more committed to using condoms and were more likely to have
higher levels of sexual enjoyment with women. In their study, the authors found that
heterosexual men often communicated their desire to wear a condom to avoid contracting
HIV and genital herpes.
Homosexual Men
In a 2005 study, Stein, Rotheram-Bors, Swendeman, and Milburn reported that of
the 250 homosexual male participants surveyed, the average number of reported partners
within a three-month period was seven. In addition, nearly 25% of those individuals
reported never using condoms during intercourse. Osmond, Lance, Pollack, and Catania
(2007) queried men in Chicago, Los Angeles, New York, and San Francisco about their
risky sexual behaviors in their past and categorized them into six different hierarchal
categories:
25
No male sexual partners, no anal intercourse partners, anal intercourse with 100%
condom use (protected partners), anal intercourse without 100% condom use but
only with partners thought to have the same HIV serostatus as the respondent,
unprotected anal intercourse in which insertive partner was HIV negative and the
receptive partner was HIV positive or serostatus known, and unprotected anal
intercourse in which the receptive partner was HIV negative and the insertive
partner was HIV positive or serostatus known. (p. 1678)
Three trends were found: during the time of the study (1997-2002), 1) HIV
infection increased; 2) risky sexual behaviors also increased, and a shift from avoiding
anal intercourse or engaging in intercourse with a condom occurred; 3) partners asked
about the HIV status of the other person in order to reduce the risk of transmission
(Osmond et al. 2007).
When looking at MSM, Preston, D‘Augelli, Kassab, and Starks (2007) reported
that the risk among this community includes a preference for receptive anal sex, multiple
unknown partners, unprotected sex, as well as possible substance abuse during
intercourse. The researchers also addressed other important considerations within this
community that may affect risky behaviors, including age, education, access to the
Internet, and psychological well-being.
When working with homosexual men toward safe sex education, Griffen et al.
(2006) reported that it is important to discuss continual use of the condoms as a
protective measure for HIV. This education should include, but not be limited to, the
dangers of ―barebacking‖ (anal sex without a condom) and intravenous drug use. Stein,
26
Rotheran-Borus, Swendeman, and Milburn (2005) reported that when talking to
homosexual men about drug use, focusing on coping styles and healthy peer relations
should be a focus of treatment.
Heterosexual women
Chin (1999) suggested that a women‘s sexual health to some extent depends on
the health of her male partner(s). Given this, sexual interactions are critical and important
to determine and examine how a woman thinks and feels when engaging in sex. Chin
(1999) suggested looking at a woman‘s schemata (her internal view of herself, self worth
and self efficacy) to understand how she organizes experiences, provides meaning to
sexual activities, and processes or interprets her actions. When related to risky sexual
behaviors, if a woman‘s schemata are not strong, she may not be comfortable inquiring
about her partner‘s sexual history, his HIV status, or asking him to use a condom. Chin
(1999) stated that with regard to one-night stands, women with poor schemata may
―guess‖ the extent of her partner‘s safety visually rather than ask him.
When examining mutually shared conversations between partners that result in
sexual scenarios or sexual scripts, Dworkin, Beckford, and Ehrhardt (2007) found that the
analysis of sexual scripts were vital for safer-sex practices. The partners could
communicate their needs, make decisions, and shape their own and the other‘s actions in
sexual negotiations. For example, the researchers found that 95% of women studied felt
that the use of condoms did not ruin their ―ideal‖ sexual scripts (Dworkin et al., 2007).
When the researchers queried the women about asking the men to use a condom at the
27
time of penetration, 29% of women reported stopping and asking for her partner to put on
a condom.
Also, many sexual risk behaviors are related to drug use or intoxication
(Cooperman, Falkin, & Cleland, 2005). Therefore, an increase in HIV/AIDS infections
has occurred. Women using recreational drugs could have a direction impact on their
decisions to engage in sexual risk behaviors (Cooperman, 2005).
Homosexual Women
Morrow and Allsworth (2000) stated that the reporting of HIV among lesbian
women is typically self identified and has only recently been studied. Of the 267 females
studied (both lesbian and bisexual, 53% reported having had an HIV test at least once,
two women reported being positive, and 9% of the women studied had not been tested.
Although the risk remains unclear, the researchers note that lesbian women are at risk for
the human papillomavirus (HPV) and anogenital warts, the same as heterosexual women.
When compared to bisexual women, lesbian women appeared to have fewer
partners over the course of the year, but they had more partners who defined themselves
as lesbian (having sex with females only) as opposed to bisexual (having sex with males
and females). Bisexual women reported using dental damn during sex, whereas lesbian
women were less likely to suggest safer sex practices.
A Comparison of Homosexual and Heterosexual
Dew, Elifson, and Sterk, in their 2007 study of homosexual and nonhomosexual
male methamphetamine users, found that both heterosexual men and homosexual men
put themselves at risk for contracting HIV, hepatitis, and other STD‘s. The authors noted
28
that heterosexual men tended to engage in less risky behaviors than did homosexual men,
however, nearly one half of the heterosexual males studied reported having had sex with
someone who was a methamphetamine drug user. Among women, lesbian women
reported safe sex practices more often than did heterosexual women (Mattew,
Brandenburg, Johnson, & Hughes, 2003). Mattews, Brandenburg, Johnson, and Hughes
(2003) reported that although lesbian women reported safer sex practices, the same safe
sex education should be given to all women to decrease the risk of HPV.
Research on college campuses studied primarily heterosexual students who were
sexually active. Research was limited to the sexual practices of same-sex sexual contact
and opposite-sex sexual contact. Eisenberg (2001) reported that the ―…bulk of the
literature on college students‘ sexual behavior employs samples of several hundred
students, which would be unlikely to include sufficient numbers of students reporting
same-sex sexual contact to conduct appropriate analyses…‖ (p. 576). Eisenberg (2001)
also argued that research into individuals identified as lesbian, gay, or bisexual is limited
and usually collected from support organizations or educational programs. This fact
makes it difficult to appropriately analyze and generalize the findings. For example,
Eisenberg‘s (2001) research on the differences of sexual health practices among college
students with same-sex versus opposite-sex partners found that ―…female students
reporting both-sex partners and males with both-sex partners and only same-sex partners
were more likely to report multiple sexual partners than students with only opposite sex
experiences‖ (p. 585).
29
Gender
A review was done of gender differences between men and women engaging in
sexual risk behaviors. In a study by Fischtein, Herold, and Desmarais (2007), the
researchers concluded that men thought about sex more frequently than did women, were
more likely to engage in oral sex, and lost their virginity at a younger age. Specifically,
those persons who were single, had higher education, and did not attend religious
services on a regular basis were more likely to engage in risky sexual practices. The
progression from thoughts of sexual activities and reality was not discussed. The
researchers also noted a larger difference exists between the number of lifetime partners
between males and females, with males reporting higher numbers of sexual partners than
females. However, it is important to note that the researchers found that men and women
may be using different strategies to determine the number of partners with whom they
have had intercourse, and, therefore, this discrepancy may account for some of the gender
differences within the literature.
When examining gender differences in other cultures, Rugpoo (2008) researched
condom use among Thai couples and suggested it is vital to educate Thai women on safe
sex practices and HIV. Rugpoo (2008) argued that this great need exists because of the
extramarital affairs often engaged in by Thai husbands who frequent sex workers.
Participants of the study felt that sex workers who looked cleaner (i.e., dressed as
students) were safer to have sex with. Thai women may face barriers in using condoms
with their husbands, as it could be seen as a stigma for a married person to buy condoms.
30
Also, her husband may disapprove of condoms and/or their cost. Consistent with Chin‘s
(1999) report, a women‘s sexual health can depend on her male partner, and it is
important to help educate both men and women on safe sex practices.
Culture
Because sexuality affects not only the individual but also the family, society and
culture, it is important to understand and examine how cultures and religions view sexual
risk behaviors. We turn now to an inquiry into the religious and cultural aspects that
affect sexual risk behaviors.
Religion
Research done to date has shown that students who are sexually active may report
lower levels of intrinsic and extrinsic religiosity (Zaleski & Schiaffino, 2000). Religious
identification may protect individuals from engaging in sexually risky behaviors. Jones,
Darroch, and Sing (2005) reported that greater attendance at religious services may be
associated with the timing of an adolescent‘s loss of virginity. However, if the adolescent
was already sexually active, attending religious services appeared to have no association
with decreasing sexual activity. Interestingly enough, Zaleski and Schiaffino (2000)
discovered that students who reported high levels of religiosity, both intrinsic and
extrinsic, were less likely to use condoms, and, therefore, they may represent a
population at higher risk for unsafe sexual practices.
Among adolescents who reported believing in G-d, Goggin et al. (2007) also
reported lower levels of sexual risk behaviors. The authors hypothesized that believing in
G-d may protect against being sexually risky and these people may use their beliefs as
31
strength to draw upon. Conversely, Sinha, Cnaan, and Gelles (2007) reported on the
importance of religion and risky sexual behaviors and found that African American and
Latino males reported the highest rate of sexually activity. The lowest percentage was
found in the Caucasian males group, but both African American males and Latino males
reported being more religiously active than Caucasian males. When working with
religious teenagers, it is important not to focus on whether or not they attend church or
temple or believe in G-d. Instead, one should empathize with their behaviors and the
support systems that they have, including church, family, and cultural group.
Earle et al. (2007) reported that religious women in the United States are more
likely to feel guilty about masturbating and less likely to engage in premarital intercourse.
Findings from both Jones, Darroch, and Sing (2005), and Earle et al. (2007) suggested
that religious commitment was associated with the age of sexual intercourse for the first
time, and was related to the number of partners these subjects had over their lifetimes as
well. McCree (2003) suggested that African Americans are among the most religious
―population subgroups‖ and the religious involvement that is fostered in that community
may help to modify negative behaviors.
Ethnicity
Age, education, and marital status may affect verbal and nonverbal
communication regarding sex. Quadango et al. (1998) suggested that men who are
younger, married, and/or cohabiting with women are more likely to initiate conversations
about sex. The researchers noted that in situations where women are economically
dependent on their partners or in cultures where males typically dominate, women did not
32
generally discuss sexual desires or risk, and usually did not even know about the
activities that men participated in that were putting them at risk. In fact, in Rugpoo‘s
(2008) study of Thai women, it was reported that they under-reported their husband‘s
sexual risk practices because they did not know about them.
According to Wang et al. (2007), after two years of a virtual eradication of
sexually transmitted diseases (STDs), China saw an ―explosion‖ of STDs. Sexually
transmitted diseases have increased more rapidly in females than males, and Wang et al.
(2007) hypothesized that this increase may be associated, in part, with the loosening of
governmental control over the population movement. Migrant women who are unable to
find jobs may frequently turn to sex work to make money. Migrant men who are
relatively wealthy may, therefore, have ―…increased opportunities to engage in high risk
behaviors…‖ (p. 58) with sex workers. Chinese students in rural China reported feeling
that attitudes toward sex were changing from a more traditionally conservative view to a
more liberal view (Lonn et al., 2007). However, the students reported that they still felt
that sexual activity prior to marriage was viewed as morally wrong in their society as a
whole, especially by members of the older generation. Although the younger generation
responds to strong influences from Western countries, students reported not being
comfortable talking to their parents about HIV/AIDS, due to embarrassment and their
parents‘ lack of education (Lonn et al., 2007).
Jermott, Jermott, and O‘Leary (2007) reported that while only 12% of women in
the United States are African American, 67% of women who were diagnosed with AIDS
in 2004 were African American. Among this population, Jermott, Jermott, and O‘Leary
33
(2007) also noted that the rate of Chlamydia is 10 times higher and the incidence of
Syphilis is 25 times higher among African American than among Caucasian women.
Ickovics et al. (2002) speculated that reasons for the disproportional rates may be due to
feelings of powerlessness and helplessness. According to the researchers, feelings such as
these may lead to women having ―…a short term view of the world and the consequences
of behavior due to more violent and chaotic environment, higher rates of prostitution due
to economic strain and denial of vulnerability to AIDS risk‖ (p. 339-340).
Ickovics et al. (2002) reported on the importance of examining ethnicity when
researching sexual risk behaviors in a community. The researchers noted that in the
African American community, cultural values emphasize gender relations, family
structure, and social/economic survival. These factors must be considered when
discussing and exploring sexism, racism, and oppression in this community. Ickovics et
al. (2002) also suggested that if minority women live in poverty, they could be at risk for
engaging in risky sexual practices. The researchers noted that ―…poor minority women
may be overwhelmed by the number of life stressors they experience, and AIDS risk may
be of relatively low concern when compared to the need for shelter, food, employment,
and safety that demand immediate attention….the stress that many poor minority women
experience, and the manner with which they cope with that stress, may be related to
AIDS risk behaviors‖ (p. 340).
When comparing ethnic differences among women, Farmer and Metson (2006)
found that Latina women reported using condoms less than did Caucasian women. Of
Latina women who did use contraceptives, 10% always used a condom, and 58% never
34
used one, whereas, 17% of Caucasian women always used condoms and 47% never did
(Farmer & Metson, 2006). Gutierrez, Bertozzi, Conde-Glez, and Sanchez-Aleman (2006)
reported that 17% of all births in Mexico in 2003 were of women under the age of 20. In
Mexico, adolescents living in poverty have become susceptible to sexual activity leading
to unwanted pregnancy, as well as alcohol and tobacco use (Gutierrez, Bertozzi, CondeGlez, & Sanchez-Aleman, 2006).
When comparing two European studies on sexual risk behaviors, it is possible to
see the similarities and differences that emerge (Askun & Ataca, 2007; Herlitz &
Ramstedt, 2005). In Sweden, radical measures were taken to help with the prevention of
HIV/AIDS. The Swedish government implemented mandatory sexual education
programs starting at primary school. It was discovered, however, that despite these
extreme measures, risky sexual practices did not decrease and people did not adopt safer
sexual practices. It can be concluded that neither Western nor European counties have
figured out the best possible sex education programs.
In contrast, Turkish society has maintained a viewpoint whereby men control
sexual behavior. It appears that urban communities seem to be separating from this
viewpoint and the younger generation, while still holding some of their families‘ views,
are starting to make their own decisions about their sexual practices. Askun and Ataca
(2007) found that 67% of college students at a Turkish university reported never having
had intercourse. The researchers noted that a total of 52% of men and 81% of women
reported that they were virgins. Also, only 11.4% of women reported that they had had
intercourse, while 67.8% of men reported that they had engaged in intercourse.
35
When discussing sexual risk behaviors, it is important to understand someone‘s
cultural background and the topics that they may or may not be comfortable with. As
noted, individuals from some countries and cultures are very open and willing to discuss
sex, while others are more reserved. When educating people, it is important to not only
discuss the facts, such as STD rates and the importance of using a condom, but one must
be mindful of those people in the room who are sensitive. Jermmott, Jermmot, and
O‘Leary (2007) stated it best by saying that brief, culturally sensitive, cognitivebehavioral skill building interventions are the best teaching tool for HIV/STD prevention
and safe sex education.
Comorbid Disorders
Health problems, psychological conditions, and possible substance abuse are all
important factors that could contribute to a person‘s probability of engaging in sexually
risky behaviors. All three factors can be vital in understanding why people are engaging
in sexual risk behaviors and determining what can be done to mitigate the negative
outcomes of their actions.
Health
Sandfort, Orr, Hirsch, and Santelli (2008) reported that the timing of an
individual‘s first sexual experience is related to the subject‘s long-term sexual health. The
researchers determined that having sex at an early age can be associated with HIV/AIDS
and STDs, whereas those individuals who do not engage in sex until later in life were at
lower risk. In addition, Russell, Golub, Cohen, and Mayer (2007) reported that
identification and treatment of asymptomatic STDs are critical to the prevention of new
36
infections. The researchers noted, however, that people are often unaware that they are
infected, and, therefore, they are less likely to be tested, seek treatment, or modify their
risky sexual behaviors. The researchers concluded that this avoidance of testing and
treatment may be one reason for the increase in STDs.
Psychological
When studying depression and sexual risk behaviors, Perdue, Hagan, Thiede, and
Valleroy (2003) hypothesized that depression may predispose a person to a risky
situation, such as engaging in high risk sex with a great number of partners, whereas,
specific behaviors, such as unprotected sex, may be influenced more by immediate
factors, such as fear of being rejected sexually or being intoxicated. When studying this
phenomenon in women, Sterk, Theall, and Elifson (2006) found that over time, women
who continued to experience high levels of depression and anxiety (after treatment) were
more likely to engage in drug use as well as high risk sexual behaviors. Interestingly,
women who continued to experience higher levels of anxiety were also more likely to
report higher levels of sexual risk behaviors more frequently.
Among demented patients, sexual desires may not decrease, although their
functioning in other areas may. Mayers (1994) detailed that a person with dementia who
may not be able ―….to move a spoon from a bowl to his mouth and must be fed may
retain the capability to move his hand to the thigh of his caretaker, engage in sexualized
stroking, and proceed to move his hand upward in a highly directed and sexually
aggressive manner‖ (p. 217). Women, on the other hand, may tend to cuddle, kiss or
climb on males‘ laps or into their beds in a quest for affection (Mayers, 1994). In an
37
optimal situation, patients would be able to discuss and determine the health risk of the
behaviors they will possibly be engaging in, including finding out if their partner(s) may
have an STD. However, given that that is not a possibility for most patients with
dementia, it then becomes the responsibility of the staff in the health care setting to keep
the patients safe.
Substance Abuse
Torres and Gore-Felton (2007) discussed the implications that emotional pain
may have on men who have sex with men and reported that alcohol and drug abuse has
been associated with this community and could result in an increase in the number of
incidents of unplanned sexual intercourse, indiscriminate sex, unprotected anal sex, as
well as a greater number of sexual partners. Among heterosexual men and women, a link
has also been found between substance use and sexually risky behaviors. Alcohol and
drug use has been shown to cloud judgment, disinhibit the user, and decrease pain
sensitivity during intercourse. These factors, it has been hypothesized, affect HIV
transmission (Schafer, Blanchard, & Fals-Stewart, 1994). Alcohol and drug use may
affect particular individuals differently. In fact, Schafer, Blanchard, and Fals-Stewart
(1994) report that individuals under the influence of drugs are less likely to use condoms
with new sexual partners than are those under the influence of alcohol.
Among women who smoke cigarettes, Saules et al. (2007) found an association
between cervical cancer, sexual risk behaviors, risk awareness, and health. It was found
that women who smoke cigarettes ―reported a higher frequency of talking with health
care providers about the benefits of testing for sexually transmitted diseases‖ (p. 210). In
38
addition, women who are at risk for cervical cancer (i.e., smokers) are aware of the
general risk factors but ―fail to define themselves accurately as being a member of an atrisk group [therefore suggesting that] prevention efforts may miss their target‖ (p. 208).
Interventions
It is important to understand not only the sexual risk behaviors, but, also, the
interventions and therapies that are being utilized to help this community. Bogart et al.
(2007) researched cognitive strategies used during recall of information by people who
may have engaged in risky sexual behaviors. These researchers used two main strategies:
(a) enumeration, in which the event is recalled and counted separately, and (b) estimation,
which is based on the perceived frequency at which the behavior may have occurred. The
researchers emphasized the importance of understanding the strategy being utilized, as
this strategy may have influenced the self-report of risk behaviors and ultimately the
intervention/treatment. It was found that enumeration may be more accurate than
estimation, because individuals could often recall the details of a sexual event, especially
if asked to examine them in a shorter time frame.
What was not Studied
In this broad overview it is important to know not only what is included in the
research review, but also what is excluded. Fetishism, sadomasochists, bondage, and
dominatrix have been excluded, because they are their own communities, possessing their
own norms and rules. The sexual risk behaviors common to these populations differ from
those of the general population, specifically, those who do not participate in such
activities. Therefore, it would have been hard to generalize about either group. Sex
39
workers have also been excluded, as they too have their own norms within their
community and it is difficult to generalize about their practices. Finally, persons who
have suffered from acts of violence, such as rape or sexual abuse have been excluded.
Studies that research risky behaviors among these populations have been excluded
because they lie beyond the scope of this paper.
Methods
Data Collection
Over 300 articles were reviewed from searches across the following databases:
Ohiolink, Proquest, Ebsco, Google Scholar, and PsycINFO. Article selection and
inclusion was then narrowed to 164 articles based on terminology search criteria. These
terminology search criteria included the following descriptors: sexual risk behaviors,
sexual behaviors, risk behaviors, and risky behaviors. In addition, these four main
searches were combined with the following topics: adolescents, elderly, couples, women,
heterosexual males, heterosexual females, homosexual males, health, depression, bipolar,
addiction, alcohol, drugs, health factors, disability, ethnicity, culture, therapies, and
interventions. Searches also included the terms, condom errors, chlamydia, gonorrhea,
STDs and sexual risk behaviors, STDs and sex, and safe sex practices.
Summary of the data
Inclusion/Exclusion Criteria
A critical analysis was conducted to determine the inclusion and exclusion of each
article. They were analyzed for their appropriateness for the research question. Articles
40
that were chosen included: studies, literature reviews, empirical articles on sexual risk
behaviors and other topics, such as general risk behaviors. To determine an article‘s
appropriateness, inclusion criteria were established. First, the article needed to address
either the topic of sexual risk behavior or risk behaviors with an examination of sexual
practices. Next, the article needed to study the topics of this paper, such as adolescent
sexual risk behaviors who live in China. Some articles, however, were too broad in
scope, such as research on the behavior of adolescent sex workers, college students‘ risky
drinking and driving behavior—which included the topic of risky sexual behaviors—and
articles on sexually transmitted diseases with no discussion of risk behavior. Each article
was then analyzed with regards to demographic information, sexual orientation,
limitations, and strengths. Based on this examination, the inclusion/exclusion criteria
followed the terms mentioned above exactly.
Methodology
Articles were first coded to determine categories they met within the study. The
number of codes an article could receive was not limited. The categories (referred to as
covariates) were: college students, culture, gender, heterosexual women, heterosexual
men, homosexual men, homosexual women, MSM (also known as men who have sex
with men but do not identify themselves at homosexual), adolescents, articles studying
primarily measurements, middle adulthood, elderly, substance abuse, psychological
disorders, health, therapies, religion, and miscellaneous (literature review). Not all 164
articles reviewed were used in the text of this study; however, 164 articles were utilized
to determine the overall percentages of the codes that emerged. This allowed for a better
41
understanding of the research. Articles are referenced in Appendix B excluding websites
that were used to collect data for the pamphlet. Only non-literature review articles were
coded. Coding was determined by the categories mentioned within each article. The
codes were used to establish an understanding of how thoroughly each covariant had
been examined within the literature to date.
Nine categories were established to examine the articles more closely. Sex, age,
ethnicity, assessments, procedures, limitation, heterosexual, homosexual, and covariates
were all entered into an Excel database. Within the categories, various choices were
available. For example, under the category ―sex‖ either male, female, both, or not stated
could be selected. These options came directly from the articles. Upon emergence of a
new term the database was updated to maintain consistency and accuracy.
Within sex, the categories were: male, female, both, or not stated. Age was
entered as the authors stated the ages in the articles, then categorized based on how the
ages were presented in the paper. The categories consisted of adolescents, 12-17; young
adults, 18-30; middle adults, 31-55; later adulthood/elderly, 55+; and a new category of
multiple age ranges. This category was needed since some articles included a broad range
of ages. The category of ―not stated‖ was also included for articles that did not report the
age of the participants. Age ranges as reported in this study differ from age ranges
reported variously in the articles studied, because as more articles were reviewed the age
ranges broaden making it more complex to determine exact age ranges, which is why
multiple age ranges was added.
42
Ethnic categories were developed directly from the research articles, as follows:
Caucasian, African American, Hispanic, Asian, Not stated, All (only Caucasian, African
American, Hispanic, or Asian subjects), Caucasian and African American solely,
Caucasian, African American and Hispanic solely, Caucasian and Hispanic solely,
primarily Caucasian, Hispanic and African American solely, and, Caucasian, Hispanic,
African American, and Native American. I acknowledge the fact that ethnicities often do
not fit into clear cut categories and that much diversity is involved. For example, using
the term Asian can be misleading, because the reader does not know which Asian culture
is being referenced. People from China, Japan, and Korea consider themselves ―Asians,‖
but they are also from different cultures, just as the people born in America of ―Asian‖
decent are culturally different from a native-born Asian. However, the terms used were
pulled directly from the research articles, and, therefore, if distinctions were made in the
participants‘ sections, they would have been noted in the data sheets.
Assessments used within each article varied tremendously, and, therefore, it was
difficult to categorize all of the assessments into a few categories. All assessments
utilized were documented into the Excel spread sheet, placed into 12 categories, and
examined. Due to the board range of assessments chosen, even within a single study, the
assessment category was determined by the primary assessment used. For example, if an
author created a survey and used multiple questionnaires, these would be placed under
the multiple questionnaires category because those surveys were their main assessment.
This categorization was determined by the authors‘ descriptions of assessments and how
they were utilized in the study. The categories developed were as follows: ―multiple
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questionnaires‖ describing any article that had chosen to use more than one questionnaire
in the methodology section, assessments created by the authors, medical only surveys
solely utilized in college classes, computer-assessed interviewing programs, models that
used both standardized interviewing and medical procedures, surveys, questionnaires that
specifically stated that demographic information was a component of the questionnaire,
self-reporting measures, interviews, self-administered assessments, and semi-structured
interviews.
Procedures within this paper were defined as the methods or methodology in
which the researchers used to assess the participants. Within the procedure section, all the
articles‘ procedures were placed into the data spread sheet as they were detailed by the
authors. Following examination, the articles were placed into 11 categories that were then
analyzed. These categories consisted of computer-assisted surveys, in-home interviews,
small groups, paper-and-pencil questionnaires, research-assisted questionnaires,
structured interviews distributed to students during classes, interviews, not-discussed
questionnaires (self administered), and self reports.
After categorization occurred, the limitations sections of the articles reviews were
analyzed in two ways. First, a review of the authors‘ limitations were noted and detailed.
Second, any information that was omitted (such as a limitations section) was noted in the
limitations section and categorized into nine major themes. The themes that emerged
were: self report, cross-sectional research, cross-sectional and self-report research,
authors who did not mention the assessments used in the articles, no limitations section in
44
the article, findings which were not generalizable, restricted to testing students who were
at school on the day of testing, self report, and a small sample size.
Sexual orientation was charted using the terms heterosexual and homosexual in
individual columns. Within each column, a choice of Yes, No, or Not Stated was given.
The gender was not needed because it was detailed next to the columns in the covariates
sections. Sexual orientation was never assumed and may account for the large percentage
of not stated, which will be addressed in the integration section.
Integration of Articles
Gender
When reviewing the category of gender, it was found that a majority of articles
included both men and women (60%) in addition to often including adolescents and
college students. When examined further, studies that sampled both genders and
adolescents made up 26 % of the articles reviewed, while college students were the focus
of 22% of the articles. Most articles including both men and women made no gender
related distinctions in their findings. When studying adolescents and college students,
authors tended to avoid questions on sexual orientation. A total of 28% of college student
articles, and 39% of articles on adolescents, did not state or ask about sexual orientation.
Of the articles reviewed, the highest percentage that researched heterosexual females
were college-specific (7%). This was followed by articles that researched substance abuse
and stated that their participants where heterosexual (4%). Figure 1 displays the
percentage of gender differences among the 164 articles examined.
45
Figure1- Percent of articles reviewing sexual risk behaviors, by gender.
Age
Regarding the age of participants, the category ―multiple age ranges‖ was found
to be most prominent. A total of 27% of the articles studied multiple age ranges as
defined by this paper. A common age range was adolescent (age 16) to late 50s. This
broad age range brings into question the generalizability of the data.
Sterk, Theall, and Elifson, (2006) studied African American women between the
ages of 18 and 59 who used drugs. The aim of the study was to reduce HIV infection for
women who were HIV negative, but were at risk because of their intravenous drug use.
The large age range in the study was not addressed. Yet, women in their early 20s may
respond differently from women in their 50s.
When examining other variables, the largest populations studied were, again,
adolescents and college students—11% and 32% respectfully. However, the most
46
surprising results were that 11% of the articles reviewed did not state the ages studied.
Kaeser (1996) researched perceptions that people who are profoundly mentally retarded
engage in sexually risky behaviors. When discussing demographics, including age, in his
methods section, Kaeser (1996) stated ―. . . there was no attempt to learn the age of
persons, their race, gender, or place of residence‖ (p. 311). Figure 2 illustrates the agerange- percentages among the 164 articles examined.
Figure 2 – Age percentages of articles researching sexual risk behaviors
Ethnicity
Thirty-three percent of articles reviewed did not state the ethnicity of participants.
This finding was unexpected because without knowing the ethnicity, a reader cannot infer
differences among cultures. Caucasian, African American, Hispanic, and Asian
ethnicities were the populations most often studied (22%) and most frequently among
adolescents. Two groups, one consisting of Caucasian, African American, and Hispanic
47
individuals, and the other, Caucasian and African American individuals, were the next
most prominent ethnicities studied. Combined they accounted for 9% of the studies
reviewed. Among the total articles reviewed, ethnicities among the participants were
limited. When expanded over multiple age ranges, only Caucasian, African American,
Hispanic, and Asian ethnicities were found in 4% of the articles, and Caucasian,
Hispanic, African American, and Native American made up 3% of the articles reviewed.
Figure 3 displays the percentage of articles that included ethnicity information among the
164 articles reviewed.
Figure 3- Ethncity percentages among articles examining sexual risk behaviors
Assessments
Multiple questionnaires, containing three to four variables each, were the
primaryassessment instruments used among thirty-seven percent (37%) of the articles
examined. For example, Huebner, and Howell (2003) studied multiple variables, such as
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sexual risk taking, parent-adolescent communication, parental monitoring, and parenting
styles. Similarly, Kiene, Tennen, and Arneli, (2008) assessed for condom-use attitudes,
self-efficacy of using condoms, condom-use behavioral intentions, and sexual behaviors.
Results were often reported as correlations between the various target dimensions
assessed. Generalizability was often limited due to a lack of statistical significance,
related to methodological difficulties with sample population, size, or assessments used.
Demographic information is always necessary to describe a sample, and was often
included as part of the questionnaires used to secure data on the chosen topic of research
(13%). For example, Kalichman, and Cain (2004), studying gender differences among
persons receiving services at STD clinics, included demographic information, such as
age, years of education, income, gender, and ethnicity. In addition, they measured sexual
compulsivity, alcohol use outcome expectancies, substance use, and sexual behaviors.
Including demographic information in such articles allowed the authors to conclude that
their sample over-represented African American people who had a history of sexually
transmitted diseases. This overrepresentation needed to be considered when the results
were interpreted. Demographic information collected is a very important aspect of
assessment because it allows the reader to better understand the sampled population as
well as the generalizability of findings. Figure 4 illustrates percentages of various
assessment methods reported among the 164 articles examined.
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Figure 4 – Percentage of assessment methods used in articles examining sexual risk
behaviors
Procedures
Surprisingly, only 7% of articles noted that the creation of their own survey was a
crucial part of their approach to assessment . While authors who used multiple
questionnaires may have created their own, they did not emphasize its importance, a
situation illustrated by Stacy, Stein, and Longshore (1999). They described the
development of four scales to specifically measure what they defined as ―past drug use.‖
The authors used their own assessments to define past alcohol use by calculating the
number of 12-ounce cans or bottles of beer, six-ounce glasses of wine, or one-ounce
drinks of hard liquor consumed during a ―typical‖ week, during the past year. Creating
their own assessment tools can allow the researchers to study exactly what they wish;
however, the tool can lack the reliability and validity that standardized measures
presumably have.
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Additionally, Gebhardt, Kuyper, and Dusseldorp (2006), created their own
measurement of condom usage when subjects were having sexual intercourse for the first
time. The authors created a 20-item questionnaire focusing on cognitive preparations and
motivations for sex and condom use. However, they did not address the issues that could
arise from a self-created assessment instrument.
An unexpected result was that self-reported data was often considered to be a
limitation (29%), while other noted in other researchers work to be a strength. Champion,
Shain, Piper, and Perdue (2001) reported that utilizing self report measures when
examining minority women with STD‘s yielded results twice those of researchers who
had used surveys and other questionnaires. However, the authors acknowledged that
while self reporting was a strength of the study, it was also a limitation because self
reporting is difficult to standardize. Gebhardt, Kuyper, and Dusseldorp (2006) also noted
self reporting as a potential limitation because questions are of a retrospective nature and
caution should be used when interpreting. When examining the procedures identified in
the articles, the most notable finding was the significant use of either self administration
and/or interviews to collect interview data. Choi, Wojcicki, and Valencia-Garcia (2004)
detailed the process of self administration by giving the subjects a standardized
questionnaire that followed the completion of an interview. In addition to the self
administered questionnaires the participants were given condom training for 10 minutes,
and they also received a one-month supply of condoms and a diary to document their
condom use. This methodology showed the importance of utilizing questionnaires and
teaching as a procedure.
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In contrast, Bogart, Walt, Pavlovic, Ober, Brown, and Kalichman (2007) used
only interviews at inner-city STD clinics. They relied on audio taping and transcriptions
to collect information from patients who recalled sexual behaviors. They found that 12
interviews were unable to be recorded due to taping malfunctions and those interviews
were lost to data collection. Relying solely on audio taping as the method of data
collection was a limitation of the researchers and therefore their results had to be
interpreted with caution.
The method of assessment distribution was another important consideration
within the articles reviewed. Four percent of the articles discussed distributing
assessments in high school and college classrooms. Huebner and Howell (2003) detailed
giving a 174-item anonymous questionnaire during high school by administering the
survey on one day, to all students present who had parental consent. No attempt was
made to address limitations that may arise when assessing students in classrooms. Shrier,
Emans, Woods, and DuRant, (1996) stated that when sampling students during class,
researchers may be underestimating the true prevalence of students who are sexually
risky, because risky behaviors are associated with poor school attendance and dropping
out of school. This consideration should be made when interpreting studies where the
researchers assessed only students at school. Figure 5 displays the percentage of articles
that discussed procedure methodologies used among the pool of articles examined.
52
Figure 5 – Percentage of methodology procedures used in articles examining sexual risk
behaviors.
Limitations
Twenty-nine percent of the articles reviewed did not mention limitations in their
studies. This omission is believed to be problematic because it does not address the
potential generalizeability of findings. It is helpful when authors acknowledge limitations
of their studies so that potential problems can be recognized and discussed. For example,
when studying the influence of religious affiliation on sexual initiation and condom use
among people in Zambia, Agha, Hutchinson, and Kusanthan (2006) found that religious
affiliation‘s influence on the risk of HIV infection was minimal. The authors did not
include a limitations section in their articles, which would have been important because
their sample consisted mainly of Seventh Day Adventists, Jehovah‘s Witnesses, and New
Apostolic Church members. Such persons may have had their own religious
considerations that were not discussed. Furthermore, because of the limited nature of the
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religious sample, the results cannot be generalized to other religions or secular groups.
Similarly, Jones, Darroch, and Singh (2005) discussed religiosity within the United States
but only among persons affiliated with fundamentalist Protestant churches. Although the
researchers did discuss other limitations within their study, they did not discuss the
homogeneity of the sample.
Similarly, Catania, Coates, and Kegeles (1994) studied the distribution of HIV
and other STDs including HIV and STD risk behaviors among heterosexual men and
women and their correlates across social strata. The authors discussed that the labeling of
a person‘s sexual past may place them at risk for HIV. However, with regard to this
specific finding, the authors did not explicate differences that labeling might cause
among the sexes, ethnicities, or ages. The authors noted that the self reporting of condom
use with HIV and STD infections appeared to be valid; however, self reporting and
perhaps under –reporting is commonly considered to be a limitation in articles discussing
sexual risk behaviors. Additionally, Dew, Elifson, and Sterk (2007) and Gullette and
Lyons (2006) all agreed that using self reporting as a measurement—while the practice is
considered acceptable and was used in both studies—should be noted as a limitation.
Gullette and Lyons (2006) noted that when relying on self reporting, it is important to
understand that behaviors may be over or under reported or reported inaccurately. When
recalling sexual activity, people make mistakes, especially when reporting condom use.
In light of this problem, 29% of articles reviewed discussed the limitations of self
reporting as an assessment tool. For example, Hallfors, Waller, Bauer, Ford, and Halpern
(2005) noted that self reporting can be misreported, and suggested utilizing computer-
54
assisted interviewing to increase accuracy. Using laptops to collect sensitive material,
such as sexual activity, substance abuse, and depression, these researchers collected
detailed and presumably accurate and self-reported data from a sample of adolescents.
They suggested that candidness was possible because the teens were not asked to answer
the questions while facing an interviewer. Hendershot, Stoner, George, and Norris (2007)
also used computer-assisted assessments to research sensation-seeking as a predictor of
HIV risk and sexual risk behaviors in adolescents. They noted that self reports of sexual
risk behavior may be inaccurate. Additionally, within the adolescent populations
sampled, drinking incidence could be higher than in the general population. With that
said, the use of computer-assisted programs allowed the researchers to conclude that
drinking alcohol before sex may predispose an individual to sexually risky acts. This
finding did not differ among genders. It should be noted, however, that authors may not
know all the limitations of their studies and could refer to the inability to generalize the
result within the discussion. Figure 6 illustrates in percentages the kinds of limitations
reported by the authors among the 164 articles examined.
55
Figure 6 – Percentage of limitations in articles examining sexual risk behaviors as
described by the authors
Sexual Orientation
Authors commonly did not state sexual orientation of participants unless they
were specifically researching a particular orientation. Almost half of the articles reviewed
did not state whether the sample was heterosexual (43%), and over half did not state
whether the population studied was homosexual (50%). Often, in articles such as Farmer
and Meston (2006) that researched condom use as well as self efficacy and attitudes
among an ethnically diverse college sample, demographics included, sex, age, and
ethnicity, but excluded sexual orientation. These authors noted that the majority of the
people sampled were sexually active and in relationships. However, nowhere in the
article was the specific sexual orientation of the participants noted. Omitting data on
56
sexual orientation is a limitation within articles that studied sexual orientation, as this fact
may be an important aspect of sexual risk behaviors.
Pinkerton, Abramson, and Holtgrave (1999) developed a model delineating cost
differences in condom use between heterosexual and homosexual men. They calculated
the cost of a condom and compared that number to the medical cost for individuals in the
at-risk population. The researchers found that if high risk heterosexual men were to use
one additional condom, the saving of HIV-related medical care cost would decrease by an
estimated $40 million. In contrast, the authors noted that homosexual men are at greater
risk than are heterosexual men, presumably because of the likelihood of increased anal
sexual activity. The authors hypothesized that a condom which initially costs
approximately $.25 would cost society $270.00 if a man was to have unprotected sex 50
times, because of the health care needed for him. These findings are important because
they illustrate that sexual risk behaviors are problematic and expensive, regardless of
sexual orientation. Dew, Elifson, and Sterk (2007) noted that both heterosexual and
homosexual men put themselves at risk for contracting HIV, hepatitis C, and other STDs,
although homosexual men may be at greater risk. More research is needed that includes
sexual orientation as the research in sexual risk behaviors continue. Figure 7a
(heterosexual) and 7b (homosexual) displays the percentage of articles that examined
sexual orientation among the 164 articles examined.
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Figure 7a-
Figure 7b –
Percentage of articles examining
Percentage of articles examining
heterosexuality and sexual risk behavoirs
homosexuality and sexual risk behaviors
Covariates
When analyzed, 22% of the articles studied youth. When examined more closely,
70% of the articles studied mainly youth while 15% studied youth and culture. For
example, Christianson, Johansson, Emmelin, and Westman (2003) studied adolescents
who may have been infected with Chlamydia in Sweden. Their results suggested that the
term youth implied immortality, in the minds of young people, and the concept of ―it
won‘t happen to me‖ was common among this population as well. Therefore, these young
people may have been more likely to engage in risky behavior. However, one must note
the cultural morals in Sweden; the authors wrote, ―Scandinavia is known for its liberal
attitudes toward sexuality. Love and intimacy between young people are discussed
openly, and mostly accepted‖ (p. 44). In addition, the authors noted that sexual
intercourse before marriage is common in Sweden, and sex education classes have been
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mandatory in schools since the mid-1950s. Such attitudes differ from other cultures, such
as those in conservative segments of America. Noting the country and its morals is
important when interpreting data.
In considering the covariants, the next largest category researched was college
students. A total of 15% of the articles reviewed studied people attending college. People
in college comprise a unique population of young adults who are at higher risk for
engaging in high risk sexual behaviors (Flannery, Ellingson, Votaw, & Schaefer, 2003),
and this fact could be attributed to biological, psychological, and environmental changes
that occur as one transitions to college (Schneider & Morris, 1991).
In light of this, Eight percent of the articles examined health risks that are
affecting this population. Both Saules et al., (2007) and Flannery, Ellingson, Votaw, and
Schaefer (2003) examined different health risks associated with college students as a
result of engaging in sexual risk behaviors. Saules et al. (2007) found that women who
smoked reported multiple sex partners, lack of condom use, excessive alcohol use, and
abortion. Flannery, Ellingson, Votaw, and Schaefer (2003) reported on health risks
associated with anal sex and noted that within the sample studied, 26% of the women
reported having an STD. These authors highlighted health concerns regarding anal sex
and stated that ―anal intercourse is associated with hepatitis B, infection, anorectal human
papilloma virus, and cancer in women" (p. 229). They stressed that anal sex behaviors be
incorporated into sex education classes because of these health risks. Figure 8 displays
the covariate percentages that studied the overarching themes among each of the 164
articles examined.
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Figure 8 – Covariate percentages among articles that studied sexual risk behaviors
Development of Pamphlet
When writing the pamphlet, I targeted age, gender, sexuality, and other variables,
toward the population that was determined as being the most at risk for engaging in high
risk sexual behaviors. It was clear that persons between the ages of 18-25 were at the
highest risk to themselves and to their sexual partners, and, therefore, more education is
needed in this group. Because college can be a time of transition and emerging
independence (and this independence includes biological, psychological, emotional, and
environmental changes), a person can become at risk for engaging in sexual behaviors
that they are not emotionally or physically ready for. For example, Gullette and Lyons
(2006) found that when both men and women who are 18-25 use alcohol, they were less
likely to use condoms and are less likely to be tested for HIV/AIDS.
Over 25,000 cases of AIDS were reported in one year for persons between the
ages of 20 and 24 (Parsons et al., 2000). In 2006, 28% of all newly reported cases of
HIV/AIDS were individuals who were likely infected during their college years (Gullette
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& Lyons, 2006). Mis-information, or lack of information, exists. Parsons et al. (2006)
reported that college students were embarrassed about asking how to use condoms and
where to obtain them. They thought that condoms could be ineffective and unnecessary,
which could lead to their having unprotected sex.
College campuses and health care centers allow for a platform of interventions
regarding sexual behaviors (Eisenberg, 2001). Therefore, it is important to work toward
developing materials that are not only educational but allow for the facilitation and ease
of discussion with health care providers. Although this research refers to this age group
as college age (possibly assuming that everyone is in college), this pamphlet is designed
to reach all persons who are between 18 and 25 and is not limited only to persons who are
in college.
In developing this pamphlet, I researched the ways in which written material, such
as pamphlets, can effectively educate a general, though targeted, audience. Fredam,
Damus, and Merkatz, (1999) stated that documents can reinforce information that people
have been taught verbally. Green (1998) reported that the use of pamphlets can contribute
directly to the knowledge of individuals by emphasizing healthy choices with regard to
sex education. In addition, Green (1998) reported that many individuals get the bulk of
their information from peers, not their parents, and written materials are another practical
way of educating people. In order to grab the attention of younger adults, Fredam,
Damus, and Merkatz, (1999) suggested that pamphlets must relate to individuals through
text and illustrations referring to age and culture. They must be easy to read, well
organized, and attractively illustrated.
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When developing my pamphlet, I began searching for stock images in
iStockphoto.com and Dreamstime.com to find images that would intrigue younger adults.
Stock images were purchased from the two sites and rights are included to use at my
discretion. My searches included the words, sex, sexual activity, sexual intercourse,
regret, college, love, drugs and alcohol, homosexual men, homosexual women, gay,
lesbian, condoms, and birth control. Images were chosen based on emotional reaction
and common usage by the target audience. Real persons were chosen as illustrations,
because they werebelieved to be more personal than drawings. I looked at people‘s faces
and body language to determine possible emotional reactions to the image. Paul,
Redman, and Sanson-Fisher (2003) advise that the use of color and images allow for a
pamphlet to be more relatable. I also believe that having an emotional reaction to an
image is more likely when the reader is able to read the material and relate to it.
Paul, Redman, and Sanson-Fisher (2003) noted that effective pamphlets contain
short words and sentences, and use messages and headings that will grab attention.
Fredam, Damus, and Merkatz, (1999) reported that pamphlets should be written at a sixth
grade reading level. Although the research often refers to this population as ―college
students,‖ this pamphlet is geared toward all persons between the ages of 18-25. It is also
important to incorporate today‘s language and communication style in the pamphlet.
With the use of cell phones and texting, people‘s communication has become shorter and
written ―in code.‖ The use of vernacular language known to this population will draw
attention to the pamphlet‘s validity. Such text words as OMG, WTF, and IDK have been
chosen because they are widely known to this age range and are relatable.
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The pamphlet is designed in six sections. The cover is intended to grab the
attention of the reader by using common text words and images. The four inside leaflets
are divided into subsections that focus on the following topics: heterosexuals,
homosexual men and women, STDs, testing, and conversation starters. The back page
contains a list of testing sites. As well, legal rights are explained, with a statement that
credits the references and stock images used to create the pamphlet. Details in the
sections include cross-over information: For example, dental dam, a protection barrier
used during oral sex with women is discussed in both the heterosexual and homosexual
sections. The pamphlet was also designed in such a way as to try and attract all sexual
interest, such as making the images seamlessly merge together. For example, when
opening the pamphlet, images of a heterosexual couple are across from images of a
lesbian couple and two males in bed. The reasoning behind this choice was that both
heterosexual men and women and homosexual men and women would initially see an
image that is relatable.
Unfortunately, it is impossible to discuss everything regarding sexual health and
risk behaviors in a pamphlet. Therefore, certain people and sexual acts are not discussed.
The focus is placed on most harmful practices, pertaining to the health of both the at-risk
population and the general population as well, specifically, oral sex with a man, oral sex
with a woman, what to look for if you think you have an STD, barriers used for safer sex
and how to use them, anal sex safety, oral sex safety, questions to always ask your
partner, and where to get tested.
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Discussion
This study is intended to help the research and clinical community, myself
included, to develop a practical and deeper understanding of sexual risk behaviors. An
examination of current and past research, community definitions and attitudes, as well as
beliefs that have emerged about sexual risk behaviors, was done in order to gain a
comprehensive overview of the people who are engaging in sexually risky behaviors.
Throughout this paper, several at-risk populations are identified in hopes of reducing
sexual risk behaviors. This pamphlet was developed to reach the college-aged group,
deemed to be at the highest prevalence rate for engaging in risky sexual behaviors.
Filling in the gaps in the research, which includes the addition of longitudinal
studies, would help to determine the risk behaviors that people engage in throughout their
lives. Currently, the research has focused on limited demographic variables. A collective
examination of these variables expands and deepens the research communities‘
understanding of persons engaging in sexual risk behaviors.
With this research, a contribution to the research community has been made by
identifying who we can help to reduce risky sexual behavior. In addition, it will help
establish an understanding of both the addressed and unaddressed populations within the
current psychological literature, helping to reveal further research needs and related
interventions.
A pamphlet has been developed for people between the ages of 18 and 25 to help
educate them further on sexual risk behaviors. People who are 18-25 are the most at risk
because almost 80-90% of those in college are engaging in sex and one third of them are
64
not using condoms. With the rising rates of HIV, the pamphlet is designed to
communicate effectively with 18-25 year olds and educate them on the importance of
safe sex.
Sex does not affect only the two individuals engaging in the act. Being sexually
risky impacts one‘s life, family, society, and our culture. Because this study focuses on
sexual risk behaviors, it is suggested that future research should continue to focus on
people who engage in risky behaviors and explore prevention interventions. Research
should continue to examine the risk of STD and HIV/AIDS transmission and should
explore effective ways of educating persons using various interventions, such as
pamphlets and/or lectures. Risky sexual behavior may never be eradicated, but with
research and education, hopefully we can teach people to be safer and reduce the risk of
harm.
65
References
Abbey, A., Parkhill, M., Buck, P., & Saenz, C. (2007). Condom use with a casual partner:
What distinguishes college students‘ use when intoxicated? Psychology of
Addictive Behavior, 21 (1), 76-83.
Agha, S., Hutchinson, P., & Ksanthan, T. (2006). The effects of religious affiliation on
sexual inhibition and condom use in Zambia. Journal of Adolescent Health, 38
,550-555.
Askun, D. & Ataca, B. (2007). Sexually related attitudes and behaviors of Turkish
University students. Archive of Sexual Behaviors, 36, 741-752.
Bogart, L., Walt, L., Pavlovic, J., Ober, A., Brown, N., & Kalichman, S. (2007).
Cognitive strategies affecting recall of sexual behavior among high-risk men and
women. Health Psychology, 26 (6), 787-793.
Catania, J. Coates, J., & Kegeles, S. (1994). A test of the AIDS risk reduction model:
Psychological correlates of condom use in AMEN cohort survey. Health
Psychology, 13 (6), 548-555.
Champion, J., Shain, R., Piper, J. & Perdue, S. (2001). Sexual abuse and sexual risk
behaviors of minority women with sexually transmitted diseases. Western Journal
of Nursing Research, 23 (3), 241-254.
Choi, K., Wojcicki, J., & Valencia-Garcia, D. (2004). Introducing and negotiating the use
of female condoms in sexual relationships: Qualitative interviews with women
attending a family planning clinic. AIDS and Behavior, 8 (3), 251-261.
Chin, D. (1999). HIV-related sexual risk assessment among Asian/Pacific Islander
American Women: An Inductive Model. Social Science & Medicine, 49 241251.
Christianson, M., Johansson, E., Emmelin, M., & Westman, G. (2003). ―One-night
stands‖ – Risky tips between lust and trust: Qualitative interviews with
Chlamydia trachomatis infected youth in north Sweden. Scandinavian Journal of
Public Health, 31, 44-50.
Coley, R., Medeiros, B., & Schindler, H. (2008). Using sibling differences to estimate
effects of parenting on adolescent sexual risk behaviors. Journal of Adolescent
Health, 43, 133-140.
66
Cooperman, N., Falkin, G., & Cleland, C. (2005). Changes in women‘s sexual risk
behaviors after therapeutic community treatment. AIDS Education and
Prevention, 17, (2) 157-169.
Dew, B., Elifson, K., & Sterk, C. (2007). Differences in HIV sexual risk behaviors
between heterosexual and nonheterosexual male users of methamphetamine.
Journal of Drug Issues, 7 (2), 281-298.
Dracobly, A. (2004). Theoretical change and therapeutic innovation in the treatment of
Syphilis in the mid-nineteenth-century France. Journal of the History of Medicine
and Allied Science, 59 (4), 522-545.
Dreamstime.com retrieved on 4/14/09
Drew, O., Smith, Y., & Sherrard, J. (2007). What‘s new in…Sexually transmitted
diseases. Medicine, 35, 410 - 412.
Dworkin, S., Beckford, S., & Ehrhardt, A. (2007). Sexual Scripts in Women: A
longitudinal analysis of participants in a gender specific HIV/STD prevention
intervention. Archive of Sexual Behavior, 36, 269-279.
Earle, J., Perricone, P., Davidson, J., Moore, N., Harris, C., & Cotten, S. (2007).
Premarital sexual attitudes and behaviors at a religiously-affiliated university:
Two decades of change. Sexual Culture, 11, 39-61.
Eisenberg, M. (2001). Differences in sexual risk behaviors between college students with
same-sex and opposite-sex experience: Results from a national study. Archives of
Sexual Behavior, 30 (6), 575-589.
Farmer, M. & Meston, C. (2006). Predictors of condom use self-efficacy in an ethnically
diverse university sample. Achieves of Sexual Behavior, 35 (3), 313-326.
Fischtein, D., Herold, E., & Desmarais, S. (20007). How much does gender explain in
sexual attitudes and behaviors? A survey of Canadian adults. Archives of Sexual
Behavior,36, 51-461.
Flannery, D., Ellingson, L., Votaw, K., & Schaefer, E. (2003). Anal intercourse and
sexual risk factors among college women, 1993-2000. American Journal of
Health and Behavior, 7 (3), 228-234.
Fredamm M., Damus, K., & Merkatz, I. (1999). Evaluation of the readability of ACOG
patient education pamphlets. Obstetrics & Gynecology, 93 (5), 771-774.
67
Gebhardt, W., Kuyper, L., & Dusseldorp, E. (2006). Condom use at first intercourse with
a new partner in female adolescents and young adults: The role of cognitive
planning and motives for having sex. Achieves of Sexual Behavior, 35 (2), 217223.
Goggin, K., Malcarne, V., Murray, T., Metcalf, K., & Wallston, K. (2007). Do religious
and control cognitions predict risky behavior? II. Development and validation of
the sexual risk behavior-related g-d locus of control scale for adolescents
(SexGLOC-A). Cognitive Therapy Research, 31, 123-139.
Green, J. (1998). School sex education and education policy in England and Whales: The
relationship examined. Health Education Research, 13 (1), 67 -72.
Griffen, R., Snook, W., Hoff, G., Cai, J., & Russell, J. (2006). Failure to embrace the
barrier/condom use message. Journal of the Association of Nurses in AIDS Care,
17 (4), 24-29.
Gullette, D. & Lyons, M. (2006). Sensation seeking, self-esteem, and unprotected sex in
college students. Journal or the Association of Nurses in AIDS Care, 17 (5), 2331.
Gutierrez, J., Bertozzi, S., Glez, C., & Sanchez-Aleman, M. (2006). Risk behaviors of 1521year olds in Mexico lead to a high prevalence of sexually transmitted
infections: results of a survey in disadvantaged urban areas. BMC Public Health,
6, 1-11.
Hallfors, D., Waller, M., Bauer, D., Ford, C., & Halpern, C. (2005). Which comes first in
adolescence—sex and drugs or depression? American Journal of Preventive
Medicine, 29, 163-170.
Harris, L., Omam, R., Vesely, S., Tolma, E., Aspy, C., Rodine, S., Marshall, L., & Fluhr,
J. (2006). Associations between youth assets and sexual activity: Does adult
supervision play a role? Child: care, health, and development, 33, 448-454.
Hendershot, C., Stoner, S., George, W. & Norris, J. (2007). Alcohol use, expectancies,
and sexual sensation seeking as correlates of HIV risk behavior in heterosexual
young adults. Psychology of Addictive Behavior, 21 (3), 365-372.
Herlitz, C., Sci, M., & Ramstedt, K. (2005). Assessment of sexual behavior, sexual
attitudes, and sexual risk in Sweden (1989-2003). Achieves of Sexual Behavior, 34
(2), 219-229.
68
Huebner, A. & Howell, L. (2003). Examining the relationship between adolescent sexual
risk-taking and perceptions of monitoring, communication, and parenting styles.
Journal of Adolescent Health, 33, 71-78.
Ickovics, J., Beren, S., Grigorenko, E., Morrill, A., Druley, J., & Rodin, J. (2002).
Pathways of risk: race, social class, stress, and coping as factors predicting
heterosexual risk behaviors for HIV among women. AIDS and Behavior, 6 (4),
339-343.
Istockphoto.com retrieved on 4/14/09
Jermott, L., Jermott, J., & O‘Leary, A. (2007). Effects of sexual risk behavior and STD
rate of brief HIV/STD prevention interventions for African American Women in
primary care settings. American Journal of Public Heath, 97 (6), 1034-1040.
Jones, R., Darroch, J. & Singh, S. (2005). Religious differentials in the sexual and
reproductive behaviors of young women in United States. Journal of Adolescent
Health, 36, 279-288.
Kaeser, F. (1996). A survey of the perceptions of twenty-three service providing agencies
on the sexual behaviors of persons with severe or profound mental retardation.
Sexuality and Disability, 14 (4), 309-320.
Kaestle, C. & Halpern, T. (2007). What‘s love got to do with it? Sexual behaviors of
opposite-sex couples through emerging adulthood. Perspectives on Sexual and
Reproductive Health, 39 (3), 134-140.
Kalichman, S. & Cain, D. (2004). The relationship between indicators of sexual
compulsivity and high risk sexual practices among men and women receiving
services from a sexually transmitted infection clinic. The Journal of Sex
Research, 41 (3), 235-241.
Kef, S. & Bos, H. (2006). Is love blind? Sexual behavior and psychological adjustment of
adolescents with blindness. Journal of Sexuality and Disabilities, 24, 89-100.
Kiene, S., Tennen, H., Arneli, S. (2008). Today I‘ll use a condom, but who knows about
tomorrow: A daily process study of variability in predictors of condom use.
Health Psychology, 27 (4), 463-472.
Linn, S., Coupey, S. (2005). Are adolescent girls with Chlamydia infection notifying their
partners? J Pediatr Adolesc Gynecol, 18, 33-38.
69
Lohman, B. & Billings, A. (2008). Protective and risk factors associated with adolescent
boys‘early sexual debut and risky sexual behaviors. Journal of Youth and
Adolescent, 37, 723-735.
Lonn, E., Sahlholm, K., Maimaiti, R., Abdkarim, K., & Andersson, R. (2007). A
traditional society in change encounters HIV/AIDS: Knowledge, attitudes, and
risk behaviors among students in northwestern China. AIDS PATIENT CARE and
STDs, 21 (1) 48-56.
Machale, E. & Newell, J. (1997). Sexual behaviour and sex education in Irish schoolgoing teenagers. International Journal of STD and AIDS, 8 196-200.
Mattews, A., Bandenburg, D., Johnson, T., & Hughes, T. (2004). Correlates of
underutilization of gynecological cancer screening among lesbian and
heterosexual women. Preventive Medicine, 38, 105-113.
Mayers, K. (1994). Sexuality and the patient with Dementia. Sexuality and Disability, 12
(3), 213-219.
McCree, D., Wingood, G., DiClemente, R., Davis, S., & Harrington, K. (2003).
Religiosity and risky sexual behavior in African-American adolescents females.
Journal of Adolescent Health, 33, (1) 2-8.
Meade, C., Graff, F., Griffin, M., & Weiss, R. (2008). HIV risk behavior among patients
with co-occurring bipolar and substance use disorders: Associations with mania
and drug abuse. Drug and Alcohol Dependence, 92, 296-300.
Miller, J., Lynman, D., Zimmerman, R., Logan, T., Leukefeld, C., & Clayton, R. (2004).
The utility of the five factor model in understanding risky sexual behavior.
Personality and Individual Differences, 36, 1611-1626.
Moore, N. & Davidson, K. (2006). College women and personal goals: Cognitive
dimensions that differentiate risk-reduction sexual decisions. Journal of Youth
and Adolescence, 35 (4), 577-589.
Morrison-Beedy, D., Carey, M., Feng, C., & Tu, X. (2008). Predicting sexual risk
behaviors among adolescent and young women using a prospective diary method.
Research in Nursing & Health, 31, 329-340.
Morrow, K. & Allsworth, J. (2000). Sexual risk in lesbian and bisexual women. Journal
of Gay and Lesbian Medical Association, 4 (4), 159-165.
70
Mueller, T., Gavin, L., & Kulkarni, A. (2008). The association between sex education
and youth's engagement in sex intercourse, age at first intercourse, and birth
control use at risk sex. Journal of Adolescent Health, 42, 89-96.
Mustanski, B. (2007). The influence of state and trait affect on HIV risk behaviors: A
daily diary study of MSM. Health Psychology, 26, (5) 618-626.
Nagaratnam, N. & Gayagay, G. (2002). Hypersexuality in nursing care facilities-a
descriptive study. Archives of Gerontology and Geriatrics, 35, 195-203.
Nicolosi, A., Buvat, J., Glasser, D., Hartmann, U., & Laumann, E. (2006). Sexual
behavior, sexual dysfunction and related help seeking patterns in middle-aged and
elderly Europeans: the global study of sexual attitudes. World J Urol, 24, 423428.
Osmond, D., Pollack, L., Paul, J., & Catania, J. (2007). Changes in prevalence of HIV
infection and sexual risk behavior in men who have sex in San Francisco: 19972002. American Journal of American Health, 97 (9), 1677-1683.
Oswalt, S., Cameron, K., & Koob, J. (2005). Sexual regret in college students. Achieves
of Sexual Behavior, 34 (6) 663-669.
Papaharitou, S., Nakopoulou, E., Kirana, P., Giaglis, G., Moraitou, M., & Hatzichristou,
D. (2008). Factors associated with sexuality in later life: an exploratory study in a
group of Greek married older adults. Journal of Gerontology and Geriatrics 46,
191-201.
Parsons, J., Halkitis, P., Bimbi, D., & Borkowski, T. (2000). Perceptions of the benefits
and costs associated with condom use and unprotected sex among late adolescent
college students. Journal of Adolescence, 23, 377-391.
Paul, C., Redman, S., Sanson-Fisher, R. (2003). Print material content and design:
Is it relevant to effectiveness? Health Education Research, 18 (2) 181-190.
Perdue, T., Hagan, H., Thiede, H., & Valleroy, L. (2003). Depression and HIV risk
behaviors among Seattle-are injection drug users and young men who have sex
with men. AIDS Education and Prevention, 15 (1), 81-92.
Peterson, S. (2006). The importance of fathers: Contextualizing sexual risk taking in ―low
risk‖ African American adolescent girls. Journal of Human Behavior in the Social
Environment, 13 (3), 67-83.
Pinkerton, S., Abramson, P., & Holtgrave, D. (1999). What is a condom worth? AIDS
and Behavior, 3 (4) 301-312.
71
Pratt, C. & Schmall, V. (1989). College students‘ attitudes toward elderly sexual
behavior: Implications for family life education. Family Relations, 38, 137-141.
Preston, D., D‘Augelli, A., Kassab, C., & Starks, M. (2007). The relationship of stigma to
the sexual risk behavior of rural men who have sex with men. AIDS Education
and Prevention, 19 (3), 218-230.
Quadango, D., Sly, D., Harrison, D., Eberstein, I., & Soler, H. (1998) Ethic differences in
sexual decisions and sexual behavior. Archives of Sexual Behavior, 27, (1) 57-75.
Randolph, M., Pinkerton, S., Bogart, L., Cecil, H., & Abramson, P. (2007). Sexual
Pleasure and condom use. Archives of Sexual Behavior, 36, 844-848.
Risen, C., & Althof, S. (1990). Couples group psychotherapy: Rebuilding the marital
relationship following disclosure of sexual deviance. Psychotherapy, 27 (3), 45463.
Rose, A., Koo, H., Bhaskar, B., Anderson, K., Caucasian , G., & Jenkins, R. (2005). The
influence of primary caregivers on the sexual behavior of early adolescents.
Journal of Adolescent Health, 37, 135-144.
Rugpoo, S. (2008). Women‘s reports of condom use in Thai couples under intensive and
regular STI/HIV risk reduction counseling. AIDS Behavior, 12, 419-430.
Russel, C., Golub, S., Cohen, D., & Mayer, K. (2007). Urine-based asymptomatic
urethral gonorrhea and chlamydia screening and sexual risk-taking behavior in
men who have sex with men in greater Boston area. AIDS PATIENT CARE and
STDs, 21 (3), 205-211.
Rye, B. & Meaney, G. (2007). The pursuit of sexual pleasure. Sexuality and Culture, 11
(1), 28-51.
Saules, K., Vannest, N., Mehringer, A., Pomerleau, C., Lee, K., Opipari, A., Midgley, R.,
Kleinsmith, L., Sen, A., & Snedecor, S. (2007). Actual versus perceived risk of
cervical cancer among college women smokers. Journal of American College
Health, 55 (4), 207-213.
Scandell, D., Klinkenberg, W., Hawkes, M., & Spriggs, L. (2003). The assessment of
high risk sexual behavior and self-presentation concerns. Research on Social
Work Practice, 13 (2), 119-141.
Schafer, J., Blanchard, L., & Fals-Stewart, W. (1994). Drug use and risky sexual
behavior. Psychology of Addictive Behaviors, 8 (1) 3-7.
72
Schneider, D & Morris, J. (1991). Risk-taking behaviors of college students.
Environment and Behavior, 23 (5), 575-591.
Schrinmshaw, E., Rosario, M., Meyer-Bahlbrg, H., & Scharf-Matlickm A. (2006). Testrest reliability of self reported sexual behavior, sexual orientation, and
psychosexual milestones among gay, lesbian, and bisexual youths. Archives of
Sexual Behavior, 35 (2), 225-234.
Schwarcz, S., Scheer, S., McFarland, W., Katz, M., Vallerory, L., Chen, S., & Catania, J.
(2007).Prevalence of HIV infection and predictors of high-transmission sexual
risk behaviors among men who have sex with men. American Journal of Public
Health, 97 (6), 1067-1075.
Serovich, J. & Greene, K. (1997). Predictors of adolescent sexual risk taking behaviors
which put them at risk for contracting HIV. Journal of Youth Adolescent, 26 (4),
429-444.
Sherman, S. & Latkin, C. (2001). Intimate relationship characteristics associated with
condom use among drug users and their sex partners: a multilevel analysis. Drug
and Alcohol Dependence, 64, 97-104.
Shrier, L., Emans, J., Woods, E., & DuRant, R. (1996). The sexual risk behaviors and
problem drug behaviors of high school students. Journal of Adolescent Health,
20, 377-383.
Sinha, J. Cnaan, R. & Gelles, R. (2007). Adolescent risk behaviors and religion: Findings
from a national study. Journal of Adolescence, 30, 213-249.
Somers, C., & Gizzi, T. (2001). Predicting adolescents‘ risky behaviors: The influence of
future orientation, school involvement, and school attachment. Adolescent &
Family Health, 2 (1), 3-11.
Sandfort, T., Orr, M., Hirsch, J., & Santelli, J. (2008). Long-term health correlates of
timing of sexual debt: Results from a national US study. American Journal of
Public Health, 98 (1), 155-161.
Skrondal, A., Eskild, A., Thorvaldsen, J. (2000). Changes in condom use after HIV
diagnosis. Scand J Public Health, 28, 71-76.
Stacy, A., Stein, J., & Longshore, D. (1999). Habit, intention and drug use as interactive
predictors of condom use among drug abusers. AIDS and Behavior, 3, 231-241.
73
Stein, J., Rotheram-Borus, M., Swendeman, D., & Milburn, N. (2005). Predictors of
sexual transmission risk behavior among HIV-positive young men. AIDS care, 17
(4), 433-442.
Sterk, C., Theall, K., & Elifson, K. (2006). The impact of emotional distress on HIV risk
reduction among women. Substance Use & Misuse, 41, 157-173.
Torres H. & Gore-Felton, C. (2007). Compulsivity, substance use, and loneliness: The
loneliness and sexual risk model (LSRM). Sexual Addiction & Compulsivity,14,
63-75.
Vesely, S., Wyatt, V., Oman, R., Aspy, C., Kegler, M., Rodine, S., Marshall, L., &
McLeroy, K. (2004). The potential protective effects of youth assets from
adolescent sexual risk behaviors. Journal of Adolescent Health, 34, 356-365.
Von Sadovszky, V., Vahey, D., McKinney., K., & Keller, M. (2006). Emotions involved
in college students‘ sexual encounters. Western Journal of Nursing Research, 28
(7), 864-879.
Wagner, M. (2001). Behavioral characteristics related to substance abuse and risk-taking,
sensation-seeking, anxiety sensitivity, and self-reinforcement. Addictive
Behaviors, 26, 115-120.
Wang, B., Xiaoming, L., Stanton, B., Fang, X., Liang, G., Liu, H., Lin, D., & Yang, H.
(2007). Gender differences in HIV-related perceptions, sexual risk behaviors, and
history of sexually transmitted diseases among Chinese Migrants visiting public
sexually transmitted disease clinics. AIDS PATIENT CARE and STDs, 21, 57-68.
Winningham, A. (2006). Older adults and HIV/AIDS. Rural Center for HIV/AIDS
Prevention. 17, 1-2.
Williams, T., Connolly, J. & Cribbie, R. (2008). Light and heavy heterosexual activities
of young Canadian adolescents: Normative patterns and differential predictors.
Journal of Research on Adolescence, 18 (1), 145-172.
Zaleski, E. & Schiaffino, K. (2000). Religiosity and sexual risk-taking behavior during
the transition to college. Journal of Adolescence, 23, 223-227.
74
APPENDIX A
Dissertation Pamphlet: We All Have Things To Say
75
WTF…
ANALSEX
Always Ask…
- Have you had vaginal,
and/or anal sex with other
people?
- If so, how many?
- When were you last tested?
- Have you ever had an STD?
- If so, which ones?
- Do you have HIV/AIDS?
- How can we both remain safe?
We all have
things
to
say…
OMG…
SAFETY
Anal sex without a condom
or “barebacking” or “raw” is
very risky...using condoms
with lubrication can make
you ready for safer sex!
ORAL SEX
SAFETY
Dental dam for women…
Dental dam is a piece of latex
used to cover the vagina
Use a condom if you do not
have a dental dam by cutting
off the tip of a condom and
cutting up the side of a
condom or plastic wrap
Also Try!
Kissing
Dirty talk
Mutual masturbation
Fantasies
Toys (make sure you use a
condom or wash them with
soapy water)
Get Tested!!
Call the CDC-information
hotline
1-800-232-4636
www.plannedparenthood.org
This brochure is not intended to
subsitute for you health professional’s
opionion or care.
Images were retrieved from Istockphoto
and and Dreamstime.
References for information provided in
dissertation and through use of national
pamphlets
© Amanda Cohen, Antioch University,
Seattle, WA.
IDK…
WTF…
OMG…
IDK…
BTW…
76
Every 9 ½ minutes someone in
the United States will be
infected with HIV
Oral sex with a
man
Cover the penis with a
new condom each time
Use
Polyurethane
condoms if allergic to
latex
Oral sex with a
woman
Cover genital with dental
dam
Make sure no fluids leak
out from the barrier
Vaginal/Anal sex
with a woman
Cover the penis with a
condom each time
Use lubrication
Things to know…
Condoms fit all penis
sizes
Saying
a
condom
“reduces pleasure” is
NOT a reason to not use
one. A condom is better
than a STD!!
If you think you have an
STD look for…
Women
Men and Women
Unusal pain or
Sores, bumps, or
discharge
blisters near
genitals, anus or
SAFE SEX:
Barriers
Use Them…
Condoms
Vaginal sex, anal
sex, sharing
dildo/vibrator
Dental dams (can
use condom or
latex cut into a
square piece)
Oral sex with
women
Anal contact
mouth
Pain between
Pain/buring when
belly button and
urinating
vagina
Unexpected
Itching in/around
bleeding
your genitals
Pain during sex
Swelling in your
throat, flu like
symptoms
Look closely at your partner’s
genitals for signs of rashes, sores or
discharges before engaging in sex
Make sure to use plenty of lube with your
condoms and dental dams
To get more information about condoms
and free samples visit
http://www.trojancondoms.com/
http://www.onedesigncontest.com/discover/
index.htm
BTW…
When drunk and/or high
people are less likely to use
condoms
and
have
an
increase of STD and HIV
infection
77
Appendix B
Articles reviewed that met specified criteria
78
Articles Reviewed Meeting Specified Criteria
Abbey, A., Parkhill, M., Buck, P., & Saenz, C. (2007). Condom use with a casual partner:
What distinguishes college students‘ use when intoxicated? Psychology of
Addictive Behavior, 21 (1), 76-83.
Agha, S., Hutchinson, P., & Ksanthan, T. (2006). The effects of religious affiliation on
sexual inhibition and condom use in Zambia. Journal of Adolescent Health, 38
,550-555.
Askun, D. & Ataca, B. (2007). Sexually related attitudes and behaviors of Turkish
University students. Archive of Sexual Behaviors, 36, 741-752.
Beckmann, K., Melzer-Lange, M., & Gorelick, M. (2004). Emergency department
management of sexually transmitted infections in US adolescents: Results from
the national hospital ambulatory medical care survey. Annals of Emergency
Medicine, 43 (3), 333- 338.
Bickham, P., O‘Keefe, S., Baker, E., Berhie, G., Kommor, M., & Harper-Dorton, K.
(2007).Correlates of early overt and covert sexual behaviors in heterosexual
women. Archive of Sexual Behav, 36, 724-740.
Brennan, D., Hellerstedt, W., Ross, M., & Welles, S. (2007). History of childhood sexual
abuse and HIV risk behaviors in homosexual and bisexual men. American Journal
of Public Health, 97 (6), 1107-1112.
Bogart, L., Walt, L., Pavlovic, J., Ober, A., Brown, N., & Kalichman, S. (2007).
Cognitive strategies affecting recall of sexual behavior among high-risk men and
women. Health Psychology, 26 (6), 787-793.
Burazeri, G., Roshi, E., & Tavanxhi, N. (2004). Does knowledge about sexually
transmitted infections increase the likelihood of consistent condom use?
Preventive Medicine, 39, 1077-1079.
Cabral, R., Pulley, L., Artz, L., Brill, I., & Macaluso, M. (1998). Women at risk of
HIV/STD: The importance of male partners as barriers to condom use. AIDS and
Behavior, 2 (1), 75- 85.
Catania, J. Coates, J., & Kegeles, S. (1994). A test of the AIDS risk reduction model:
Psychological correlates of condom use in AMEN cohort survey. Health
Psychology, 13 (6), 548-555.
79
Champion, J., Shain, R., Piper, J. & Perdue, S. (2001). Sexual abuse and sexual risk
behaviors of minority women with sexually transmitted diseases. Western Journal
of Nursing Research, 23 (3), 241-254.
Chen, Y., Stiffman, A., Cheng, L., & Dore, P. (1997). Mental health, social environment
and sexual risk behaviors of adolescent service users: A gender comparison.
Journal of Child and Family Studies, 6 (1), 9-25.
Choi, K., Wojcicki, J., & Valencia-Garcia, D. (2004). Introducing and negotiating the use
of female condoms in sexual relationships: Qualitative interviews with women
attending a family planning clinic. AIDS and Behavior, 8 (3), 251-261.
Chimbiri, A. (2007). The condom is an ‗intruder‘ in marriage: Evidence from rural
Malawi. Social Science & Medicine, 64, 1102-1115.
Chin, D. (1999). HIV-related sexual risk assessment among Asian/Pacific Islander
American Women: An Inductive Model. Social Science & Medicine, 49 241251.
Christianson, M., Johansson, E., Emmelin, M., & Westman, G. (2003). ―One-night
stands‖ – Risky tips between lust and trust: Qualitative interviews with
Chlamydia trachomatis infected youth in north Sweden. Scandinavian Journal of
Public Health, 31, 44-50.
Coley, R., Medeiros, B., & Schindler, H. (2008). Using sibling differences to estimate
effects of parenting on adolescent sexual risk behaviors. Journal of Adolescent
Health, 43, 133-140.
Cooperman, N., Falkin, G., & Cleland, C. (2005). Changes in women‘s sexual risk
behaviors after therapeutic community treatment. AIDS Education and
Prevention, 17, (2) 157-169.Crosby, R.,
Diclemente, R., Yarber, W., Snow, G., & Trotman, A. (2008). Young African
American men having sex with multiple partners are more likely to sue condoms
incorrectly: A clinic-based study. American Journal of Men’s Health, 2 (4), 340343.
Crosby, R., Sanders, S., Yarber, W., & Graham, C. (2003). Condom-use errors and
problems. A neglected aspect of studies assessing condom effectiveness.
American Journal of Preventive Medicine, 24 (4), 367 – 370.
Dew, B., Elifson, K., & Sterk, C. (2007). Differences in HIV sexual risk behaviors
between heterosexual and nonheterosexual male users of methamphetamine.
Journal of Drug Issues, 7 (2), 281-298.
80
Dracobly, A. (2004). Theoretical change and therapeutic innovation in the treatment of
Syphilis in the mid-nineteenth-century France. Journal of the History of Medicine
and Allied Science, 59 (4), 522-545.
Drew, O., Smith, Y., & Sherrard, J. (2007). What‘s new in…Sexually transmitted
diseases. Medicine, 35, 410 - 412.
Dworkin, S., Beckford, S., & Ehrhardt, A. (2007). Sexual Scripts in Women: A
longitudinal analysis of participants in a gender specific HIV/STD prevention
intervention. Archive of Sexual Behavior, 36, 269-279.
Earle, J., Perricone, P., Davidson, J., Moore, N., Harris, C., & Cotten, S. (2007).
Premarital sexual attitudes and behaviors at a religiously-affiliated university:
Two decades of change. Sexual Culture, 11, 39-61.
Eisenberg, M. (2001). Differences in sexual risk behaviors between college students with
same-sex and opposite-sex experience: Results from a national study. Archives of
Sexual Behavior, 30 (6), 575-589.
Ellen, J., Brown, B., Chung, S., Potterat, J., Muth, S., Valente, T., & Padian, N. (2005).
Impact of sexual networks on risk for Gonorrhea and Chlamydia among lowincome urban African American adolescent. Jpeds, 11 (23), 518-522.
Elkins, D., Dole, L., Maticka-Tyndale, E., & Stam, K. (1998). Relaying the message of
safer sex:Condom races for community-based skills training. Health Education
Research, 13 (3), 357 -370.
Farmer, M. & Meston, C. (2006). Predictors of condom use self-efficacy in an ethnically
diverse university sample. Achieves of Sexual Behavior, 35 (3), 313-326.
Fenaughty, A., & Namyniuk, L. (2004). ―Here‘s what I‘d do…‖: Condom promotion
strategies proposed by high-risk women in Anchorage, Alaska. Qualitative Health
Research, 14 (1), 23-38.
Fischtein, D., Herold, E., & Desmarais, S. (20007). How much does gender explain in
sexual attitudes and behaviors? A survey of Canadian adults. Archives of Sexual
Behavior,36, 51-461.
Flannery, D., Ellingson, L., Votaw, K., & Schaefer, E. (2003). Anal intercourse and
sexual risk factors among college women, 1993-2000. American Journal of
Health and Behavior, 7 (3), 228-234.
Frank, E., Anderson, C., & Rubinstein, D. (1979). Marital role strain and sexual
satisfaction. Journal of Consulting and Clinical Psychology, 47 (6), 1096-1103.
81
Fredamm M., Damus, K., & Merkatz, I. (1999). Evaluation of the readability of ACOG
patient education pamphlets. Obstetrics & Gynecology, 93 (5), 771-774.
Gaines Jr. S. (1996). Impact of interpersonal traits and gender-role compliance on
interpersonal resource exchange among dating and engaged/married couples.
Journal of Social and Personal Relationships, 13 (2), 241-261.
Gebhardt, W., Kuyper, L., & Dusseldorp, E. (2006). Condom use at first intercourse with
a new partner in female adolescents and young adults: The role of cognitive
planning and motives for having sex. Achieves of Sexual Behavior, 35 (2), 217223.
Goggin, K., Malcarne, V., Murray, T., Metcalf, K., & Wallston, K. (2007). Do religious
and control cognitions predict risky behavior? II. Development and validation of
the sexual risk behavior-related g-d locus of control scale for adolescents
(SexGLOC-A). Cognitive Therapy Research, 31, 123-139.
Green, J. (1998). School sex education and education policy in England and Whales: The
relationship examined. Health Education Research, 13 (1), 67 -72.
Griffen, R., Snook, W., Hoff, G., Cai, J., & Russell, J. (2006). Failure to embrace the
barrier/condom use message. Journal of the Association of Nurses in AIDS Care,
17 (4), 24-29.
Gullette, D. & Lyons, M. (2006). Sensation seeking, self-esteem, and unprotected sex in
college students. Journal or the Association of Nurses in AIDS Care, 17 (5), 2331.
Gutierrez, J., Bertozzi, S., Glez, C., & Sanchez-Aleman, M. (2006). Risk behaviors of 1521year olds in Mexico lead to a high prevalence of sexually transmitted
infections: results of a survey in disadvantaged urban areas. BMC Public Health,
6, 1-11.
Hallfors, D., Waller, M., Bauer, D., Ford, C., & Halpern, C. (2005). Which comes first in
adolescence—sex and drugs or depression? American Journal of Preventive
Medicine, 29, 163-170.
Harris, L., Omam, R., Vesely, S., Tolma, E., Aspy, C., Rodine, S., Marshall, L., & Fluhr,
J. (2006). Associations between youth assets and sexual activity: Does adult
supervision play a role? Child: care, health, and development, 33, 448-454.
82
Hendershot, C., Stoner, S., George, W. & Norris, J. (2007). Alcohol use, expectancies,
and sexual sensation seeking as correlates of HIV risk behavior in heterosexual
young adults. Psychology of Addictive Behavior, 21 (3), 365-372.
Herlitz, C., Sci, M., & Ramstedt, K. (2005). Assessment of sexual behavior, sexual
attitudes, and sexual risk in Sweden (1989-2003). Achieves of Sexual Behavior, 34
(2), 219-229.
Hingsburger, D., & Tough, S. (2002). Healthy sexuality: Attitudes, systems and policies.
Research & Practice for Persons with Severe Disabilities, 27 (1), 8-17.
Huebner, A. & Howell, L. (2003). Examining the relationship between adolescent sexual
risk-taking and perceptions of monitoring, communication, and parenting styles.
Journal of Adolescent Health, 33, 71-78.
Ickovics, J., Beren, S., Grigorenko, E., Morrill, A., Druley, J., & Rodin, J. (2002).
Pathways of risk: race, social class, stress, and coping as factors predicting
heterosexual risk behaviors for HIV among women. AIDS and Behavior, 6 (4),
339-343.
Jermott, L., Jermott, J., & O‘Leary, A. (2007). Effects of sexual risk behavior and STD
rate of brief HIV/STD prevention interventions for African American Women in
primary care settings. American Journal of Public Heath, 97 (6), 1034-1040.
Jones, R., Darroch, J. & Singh, S. (2005). Religious differentials in the sexual and
reproductive behaviors of young women in United States. Journal of Adolescent
Health, 36, 279-288.
Kaeser, F. (1996). A survey of the perceptions of twenty-three service providing agencies
on the sexual behaviors of persons with severe or profound mental retardation.
Sexuality and Disability, 14 (4), 309-320.
Kaestle, C. & Halpern, T. (2007). What‘s love got to do with it? Sexual behaviors of
opposite-sex couples through emerging adulthood. Perspectives on Sexual and
Reproductive Health, 39 (3), 134-140.
Kalichman, S. (2005). The other side of the healthy relationships interventions: Mental
health outcomes and correlates of sexual risk behavior change. AIDS Education
and Prevention, 17, 66-75.
Kalichman, S. & Cain, D. (2004). The relationship between indicators of sexual
compulsivity and high risk sexual practices among men and women receiving
services from a sexually transmitted infection clinic. The Journal of Sex
Research, 41 (3), 235-241.
83
Kef, S. & Bos, H. (2006). Is love blind? Sexual behavior and psychological adjustment of
adolescents with blindness. Journal of Sexuality and Disabilities, 24, 89-100.
Krahe, B., Abraham, & Scheinberger-Olwig, R. (2005). Can safer-sex promotion leaflets
change cognitive antecedents of condom use? An experimental evaluation. British
Journal of Health Psychology, 10, 203-220.
Kiene, S., Tennen, H., Arneli, S. (2008). Today I‘ll use a condom, but who knows about
tomorrow: A daily process study of variability in predictors of condom use.
Health Psychology, 27 (4), 463-472.
Latka, M., Ahern, J., Garfein, R., Ouellet, L., Kerndt, P., Morse, P., Farshy., C., Des
Jarlais, D., & Vlahov, D. (2001). Prevalence, incident, and correlates of
Chlamydia and Gonorrhea among young adult injection drug users. Journal of
Substance Abuse, 13, 73-88.
Leonard, L., & Ross, M. (1997). The last sexual encounter: The contextualization of
sexual risk behaviour. International Journal of STD & AIDS, 8, 643-645.
Lescano, C., Hadley, W., Beausoleil, N., Brown, L., D‘eramo, D., & Zimskind, A.
(2007).A brief screening measure of adolescent risk behavior. Child Psychiatry
Hum Dev, 37, 325-336.
Lindemann, D. & Brigham, T. (2003). A Guttman scale for assessing condom use skills
among college students. AIDS and Behavior, 7 (1), 23-27.
Lindemann, D., Brigham, T., Harbke, C., & Alexander, T. (2005). Toward Errorless
condom use: A comparison of two course to improve condom use skills, AIDS
and Behavior, 9 (4), 451-457.
Linn, S., Coupey, S. (2005). Are adolescent girls with Chlamydia infection notifying their
partners? J Pediatr Adolesc Gynecol, 18, 33-38.
Little, J. (2006). Gonorrhea: Update. Oral Surgery, Oral Medicine, Oral Pathology, Oral
Radiology, and Endodontolgy, 101 (2), 137-143.
Lohman, B. & Billings, A. (2008). Protective and risk factors associated with adolescent
boys‘early sexual debut and risky sexual behaviors. Journal of Youth and
Adolescent, 37, 723-735.
Lonn, E., Sahlholm, K., Maimaiti, R., Abdkarim, K., & Andersson, R. (2007). A
traditional society in change encounters HIV/AIDS: Knowledge, attitudes, and
risk behaviors among students in northwestern China. AIDS PATIENT CARE and
STDs, 21 (1) 48-56.
84
MacHale, E. & Newell, J. (1997). Sexual behaviour and sex education in Irish schoolgoing teenagers. International Journal of STD & AIDS, 8, 196-200.
Malow, R., Devieux, J., Martinez, L., Peipman, F., Lucenko, B., & Kalichman, S. (2006).
History of traumatic abuse and HIV risk behaviors in severely mentally ill
substance abusing adults. Journal of Family Violence, 21 (2), 127-135.
Malow, R., Devieux, J., Rosenberg, R., Samuels, D., & Jean-Gilles, M. (2006). Alcohol
use severity and HIV sexual risk among juvenile offenders. Substance Use &
Misuse, 41, 1769-1788.
Manlove, J., Ikramullah, E., & Terry-Humen, E. (2008). Condom use and consistency
among male adolescents in the United States. Journal of Adolescent Health, 43,
325-333.
Mattews, A., Bandenburg, D., Johnson, T., & Hughes, T. (2004). Correlates of
underutilization of gynecological cancer screening among lesbian and
heterosexual women. Preventive Medicine, 38, 105-113.
Mayers, K. (1994). Sexuality and the patient with Dementia. Sexuality and Disability, 12
(3), 213-219.
Mazzaferro, K., Murray, P., Ness, R., Bass, D., Nadra, T., & Cook, R. (2006).
Depression, stress and social support as predictors of high-risk sexual behaviors
and STIs in young women. Journal of Adolescent Health, 39, 601-603.
McCree, D., Wingood, G., DiClemente, R., Davis, S., & Harrington, K. (2003).
Religiosity and risky sexual behavior in African-American adolescents females.
Journal of Adolescent Health, 33, (1) 2-8.
Meade, C., Graff, F., Griffin, M., & Weiss, R. (2008). HIV risk behavior among patients
with co-occurring bipolar and substance use disorders: Associations with mania
and drug abuse. Drug and Alcohol Dependence, 92, 296-300.
Metzler, C., Noell, J., & Biglan, A. (1992). The validation of a construct of high-risk
sexual behavior in heterosexual adolescents. Journal of Adolescent Research, 7
(2), 233-249.
Meyer-Bahlburg, H., Dolezal, C., Clerici, M., & Lederman, S. (1997). Sexual risk
behavior may be associated with T-Helper-Cell response to HIV-1 peptides in
HIV-and HIV+ men. AIDS and Behaviors, 1 (3), 181-190.
85
Miller, J., Lynman, D., Zimmerman, R., Logan, T., Leukefeld, C., & Clayton, R. (2004).
The utility of the five factor model in understanding risky sexual behavior.
Personality and Individual Differences, 36, 1611-1626.
Mindel, A., Marks, C., Tiderman, R., Taylor, J., Seifert, C., Berry, G., Truginger, B., &
Cunningham, A. (2003). Sexual behaviour and social class in Australian women.
International Journal of STD & AIDS, 14, 344-349.
Mnyika, K., Klepp, K., Kvale, G., & Ole-King‘ori, N. (1997). Determinants of high-risk
sexual behaviour and condom use among adults in the Arusha region, Tanzania.
International Journal of STD & AIDS, 8, 176-183.
Moore, J., Hamburger, M., Vlahov, D., Schoenbaum, E., Schuman, P. & Mayer, K.
(2001). Longitudinal study of condom use patterns among women with or at risk
for HIV.AIDS and Behavior, 5 (3), 263-273.
Moore, N. & Davidson, K. (2006). College women and personal goals: Cognitive
dimensions that differentiate risk-reduction sexual decisions. Journal of Youth
and Adolescence, 35 (4), 577-589.
Morrison-Beedy, D., Carey, M., Feng, C., & Tu, X. (2008). Predicting sexual risk
behaviors among adolescent and young women using a prospective diary method.
Research in Nursing & Health, 31, 329-340.
Morrow, K. & Allsworth, J. (2000). Sexual risk in lesbian and bisexual women. Journal
of Gay and Lesbian Medical Association, 4 (4), 159-165.
Mueller, T., Gavin, L., & Kulkarni, A. (2008). The association between sex education
and youth's engagement in sex intercourse, age at first intercourse, and birth
control use at risk sex. Journal of Adolescent Health, 42, 89-96.
Munoz-Silva, A., Sanchez-Garcia, MM., Nunes, C., & Martins, A. (2007). AIDS
preventions in late adolescent college students from Spain and Portugal. Journal
of the Royal Institute of Public Health, 121, 673-681.
Mustanski, B. (2007). The influence of state and trait affect on HIV risk behaviors: A
daily diary study of MSM. Health Psychology, 26, (5) 618-626.
Nagaratnam, N. & Gayagay, G. (2002). Hypersexuality in nursing care facilities-a
descriptive study. Archives of Gerontology and Geriatrics, 35, 195-203.
Niccolai, L., Livingston, K., Teng, F., & Pettigrew, M. (2008). Behavioral intentions in
sexual partnerships following a diagnosis of Chlamydia trachomatis. Preventive
Medicine, 46, 170-176.
86
Nicolosi, A., Buvat, J., Glasser, D., Hartmann, U., & Laumann, E. (2006). Sexual
behavior, sexual dysfunction and related help seeking patterns in middle-aged and
elderly Europeans: the global study of sexual attitudes. World J Urol, 24, 423428.
Nicolosi, A., Laumann, E., Glasser, D., Moreira, E., Paik, A. & Gingell, C. (2004).
Sexual behaviors and sexual dysfunctions after age 40: The global study of sexual
attitudes and behaviors. Adult Urology, 6, 991-997.
Noar, S., Cole, C., & Carlyle, K. (2006). Condom use measurement in 56 studies of
sexual risk Behavior: Review and recommendations,. Achieves of Sexual
Behavior, 35 (3), 327-345.
O‘Donnell, L., Stueve, A., Wilson-Simmons, R., Dash, K., Agronick, G., &.
JeanBaptoste, V (2006). Heterosexual risk behaviors among urban young
adolescents. Journal of Early Adolescence, 26 (1), 87-109.
O‘Farrell, T., Kleinke, C., & Cutter, H. (1998). Sexual adjustment of male alcoholics:
Changes from before to after receiving alcoholism counseling with and without
marital therapy. Addictive Behaviors, 23 (3), 419-425.
Osmond, D., Pollack, L., Paul, J., & Catania, J. (2007). Changes in prevalence of HIV
infection and sexual risk behavior in men who have sex in San Francisco: 19972002. American Journal of American Health, 97 (9), 1677-1683.
Ostovich, J. & Sabini, J. (2005). Timing of puberty an sexuality in men and women.
Archives of Sexual Behavior, 34 (2), 197-206.
Oswalt, S., Cameron, K., & Koob, J. (2005). Sexual regret in college students. Achieves
of Sexual Behavior, 34 (6) 663-669.
Papaharitou, S., Nakopoulou, E., Kirana, P., Giaglis, G., Moraitou, M., & Hatzichristou,
D. (2008). Factors associated with sexuality in later life: an exploratory study in a
group of Greek married older adults. Journal of Gerontology and Geriatrics 46,
191-201.
Parsons, J., Halkitis, P., Bimbi, D., & Borkowski, T. (2000). Perceptions of the benefits
and costs associated with condom use and unprotected sex among late adolescent
college students. Journal of Adolescence, 23, 377-391.
Pasch, L. & Bradbury, T. (1998). Social support, conflict and development of marital
dysfunction. Journal of Consulting and Clinical Psychology, 66 (2), 219-230.
87
Paul, C., Redman, S., Sanson-Fisher, R. (2003). Print material content and design:
Is it relevant to effectiveness? Health Education Research, 18 (2) 181-190.
Paxton, K., Myers, H., Hall, N., & Javanbakht, M. (2004). Ethnicity, serostatus, and
psychosocial differences in sexual risk behaviors among HIV-seropositive and
HIV-seronegative women. AIDS and Behaviors, 8 (4), 405-415.
Perdue, T., Hagan, H., Thiede, H., & Valleroy, L. (2003). Depression and HIV risk
behaviors among Seattle-are injection drug users and young men who have sex
with men. AIDS Education and Prevention, 15 (1), 81-92.
Peterson, S. (2006). The importance of fathers: Contextualizing sexual risk taking in ―low
risk‖ African American adolescent girls. Journal of Human Behavior in the Social
Environment, 13 (3), 67-83.
Pinkerton, S., Abramson, P., & Holtgrave, D. (1999). What is a condom worth? AIDS
and Behavior, 3 (4) 301-312.
Pinkerton, S., Layde, P., DiFranceisco, W., Chesson, H., and the NIHM Multisite HIV
Prevention Trial Group. All STDs are not created equal: An analysis of the
differential effects of sexual behaviour changes on different STDs. International
Journal of STD & AIDS, 14, 320-328.
Pratt, C. & Schmall, V. (1989). College students‘ attitudes toward elderly sexual
behavior: Implications for family life education. Family Relations, 38, 137-141.
Preston, D., D‘Augelli, A., Kassab, C., & Starks, M. (2007). The relationship of stigma to
the sexual risk behavior of rural men who have sex with men. AIDS Education
and Prevention, 19 (3), 218-230.
Quadango, D., Sly, D., Harrison, D., Eberstein, I., & Soler, H. (1998) Ethic differences in
sexual decisions and sexual behavior. Archives of Sexual Behavior, 27, (1) 57-75.
Ramisetty-Mikler, S., Goebert, D., Nishimra, S., & Caetano, R. (2006). Dating violence
victimization: Associated drinking and sexual risk behaviors of Asian, Native
Hawaiian, and Caucasian high school students in Hawaii. Journal of School
Health, 76 (8), 423-429.
Randolph, M., Pinkerton, S., Bogart, L., Cecil, H., & Abramson, P. (2007). Sexual
Pleasure and condom use. Archives of Sexual Behavior, 36, 844-848.
Ressler, R., Walters, M., & Watson, J. (2006). Contributing factors to the spread of
sexually transmitted diseases, The case of welfare. American Journal of
Economics and Sociology, 65 (4), 943-961.
88
Rink, E., Ticker, R., & Harvey, M. (2007). Onset of sexual intercourse among female
adolescents: The influence of perceptions, depression and ecological factors.
Journal of Adolescent Health, 41, 398-406.
Risen, C., & Althof, S. (1990). Couples group psychotherapy: Rebuilding the marital
relationship following disclosure of sexual deviance. Psychotherapy, 27 (3), 45463.
Rose, A., Koo, H., Bhaskar, B., Anderson, K., Caucasian , G., & Jenkins, R. (2005). The
influence of primary caregivers on the sexual behavior of early adolescents.
Journal of Adolescent Health, 37, 135-144.
Rosenthal, S., Burklow, K., Lewis, Succop, P., & Biro, F. (1997). Heterosexual romantic
relationships and sexual behaviors of young adolescent girls. Journal of
Adolescent Health, 21, 238-243.
Rostoksy, S., Galliher, R., Welsh, D., & Kawaguchi, M. (2000). Sexual behaviors and
relationships qualities in late adolescent couples. Journal of Adolescence, 23, 583597.
Roye, C. (1998). Condom use by Hispanic and African-American adolescent girls who
use hormonal contraception. Journal of Adolescence Health, 23, 205-211.
Rugpo, S. (2008). Women‘s reports of condom use in Thai couples under intensive and
regular STI/HIV risk reduction counseling. AIDS Behavior, 12, 419-430.
Russel, C., Golub, S., Cohen, D., & Mayer, K. (2007). Urine-based asymptomatic
urethral gonorrhea and chlamydia screening and sexual risk-taking behavior in
men who have sex with men in greater Boston area. AIDS PATIENT CARE and
STDs, 21 (3), 205-211.
Rye, B. & Meaney, G. (2007). The pursuit of sexual pleasure. Sexuality and Culture, 11
(1), 28-51.
Sacco, W., Levine, B., Reed, D., Thompson, K. (1991). Attitudes about condom use as an
AIDS-relevant behavior: Their factor structure and relation to condom use.
Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3
(2), 265-272.
Sales, J., DiClemente, R., Rose, E., Wingood, G., Klien, J., & Woods, E. (2007).
Relationship of STD-related shame and stigma to female adolescents‘ condom
protected intercourse. Journal of Adolescent Health, 40 573.e1- 573.e6.
89
Saewyc, E., BEaringer, L., Heinz, P., Blum, M. & Resnick, M. (1998) Gender differences
in health and risk behaviors among bisexual and homosexual adolescents. Journal
of Adolescent Health, 23, 181-188.
Saules, K., Vannest, N., Mehringer, A., Pomerleau, C., Lee, K., Opipari, A., Midgley, R.,
Kleinsmith, L., Sen, A., & Snedecor, S. (2007). Actual versus perceived risk of
cervical cancer among college women smokers. Journal of American College
Health, 55 (4), 207-213.
Scandell, D., Klinkenberg, W., Hawkes, M., & Spriggs, L. (2003). The assessment of
high risk sexual behavior and self-presentation concerns. Research on Social
Work Practice, 13 (2), 119-141.
Schafer, J., Blanchard, L., & Fals-Stewart, W. (1994). Drug use and risky sexual
behavior. Psychology of Addictive Behaviors, 8 (1) 3-7.
Schneider, D & Morris, J. (1991). Risk-taking behaviors of college students.
Environment and Behavior, 23 (5), 575-591.
Schrinmshaw, E., Rosario, M., Meyer-Bahlbrg, H., & Scharf-Matlickm A. (2006). Testrest reliability of self reported sexual behavior, sexual orientation, and
psychosexual milestones among gay, lesbian, and bisexual youths. Archives of
Sexual Behavior, 35 (2), 225-234.
Schwarcz, S., Scheer, S., McFarland, W., Katz, M., Vallerory, L., Chen, S., & Catania, J.
(2007).Prevalence of HIV infection and predictors of high-transmission sexual
risk behaviors among men who have sex with men. American Journal of Public
Health, 97 (6), 1067-1075.
Serovich, J. & Greene, K. (1997). Predictors of adolescent sexual risk taking behaviors
which put them at risk for contracting HIV. Journal of Youth Adolescent, 26 (4),
429-444.
Sherman, S. & Latkin, C. (2001). Intimate relationship characteristics associated with
condom use among drug users and their sex partners: a multilevel analysis. Drug
and Alcohol Dependence, 64, 97-104.
Shrier, L., Emans, J., Woods, E., & DuRant, R. (1996). The sexual risk behaviors and
problem drug behaviors of high school students. Journal of Adolescent Health,
20, 377-383.
Sinha, J. Cnaan, R. & Gelles, R. (2007). Adolescent risk behaviors and religion: Findings
from a national study. Journal of Adolescence, 30, 213-249.
90
Somers, C., & Gizzi, T. (2001). Predicting adolescents‘ risky behaviors: The influence of
future orientation, school involvement, and school attachment. Adolescent &
Family Health, 2 (1), 3-11.
Sandfort, T., Orr, M., Hirsch, J., & Santelli, J. (2008). Long-term health correlates of
timing of sexual debt: Results from a national US study. American Journal of
Public Health, 98 (1), 155-161.
Skrondal, A., Eskild, A., Thorvaldsen, J. (2000). Changes in condom use after HIV
diagnosis. Scand J Public Health, 28, 71-76.
Stacy, A., Stein, J., & Longshore, D. (1999). Habit, intention and drug use as interactive
predictors of condom use among drug abusers. AIDS and Behavior, 3, 231-241.
Stein, J., Rotheram-Borus, M., Swendeman, D., & Milburn, N. (2005). Predictors of
sexual transmission risk behavior among HIV-positive young men. AIDS care, 17
(4), 433-442.
Sterk, C., Theall, K., & Elifson, K. (2006). The impact of emotional distress on HIV risk
reduction among women. Substance Use & Misuse, 41, 157-173.
Symonds, T. (1998). Back school or pamphlet education: which is best for industry?
A Journal of Prevention, Assessment, and Prevention, 10, 49-53.
Tarnai, B. (2006). Review of effective interventions for socially inappropriate
masturbation in persons with cognitive disabilities. Journal of Sexuality and
Disability, 24, 151-168.
Torres H. & Gore-Felton, C. (2007). Compulsivity, substance use, and loneliness: The
loneliness and sexual risk model (LSRM). Sexual Addiction & Compulsivity,14,
63-75.
Tosh, A. & Simmons, P. (2007). Sexual activity and other risk-taking behaviors among
Asian-American adolescents. Joural of Pediatric Adolescence Gynecology, 20,
29-34.
Tschann, J., Adler, N., Millstein, S., Gurvey, J., & Ellen, J. (2002). Relative power
between sexual partners and condom use among adolescents. Journal of
Adolescent Health, 31, 17-25.
Vesely, S., Wyatt, V., Oman, R., Aspy, C., Kegler, M., Rodine, S., Marshall, L., &
McLeroy, K. (2004). The potential protective effects of youth assets from
adolescent sexual risk behaviors. Journal of Adolescent Health, 34, 356-365.
91
Visser, R. (2005). One size fits all? Promoting condom use for sexually transmitted
infection prevention among heterosexual young adults. Health Education
Research, 20 (5), 558-556.
Villarruel, A., Jemmott, L., Howard, M., Taylor, L. & Bush, E. (1998). Practice what we
preach? HIV knowledge, beliefs, and behaviors of adolescents and adolescent
peer educators. Journal of the Association of Nurses in AIDS Care, 9 (5), 61-72.
Vollrath, M. & Torgersen, S. (2008). Personality types and risky health behaviors in
Norwegian students. Scandinavian Journal of Psychology, 49, 287-292.
Von Sadovszky, V., Vahey, D., McKinney., K., & Keller, M. (2006). Emotions involved
in college students‘ sexual encounters. Western Journal of Nursing Research, 28
(7), 864-879.
Wagner, M. (2001). Behavioral characteristics related to substance abuse and risk-taking,
sensation-seeking, anxiety sensitivity, and self-reinforcement. Addictive
Behaviors, 26, 115-120.
Wang, B., Xiaoming, L., Stanton, B., Fang, X., Liang, G., Liu, H., Lin, D., & Yang, H.
(2007). Gender differences in HIV-related perceptions, sexual risk behaviors, and
history of sexually transmitted diseases among Chinese Migrants visiting public
sexually transmitted disease clinics. AIDS PATIENT CARE and STDs, 21, 57-68.
Waller, M. Hallfors, D., Halpern, C., Iritani, B., Ford, C., & Guo, G. (2006). Gender
differences in associations between depressive symptoms and patterns of
substance use and risky sexual behavior among a nationally representative sample
of U.S. adolescents. Achieves of Women’s Mental Health, 9, 139-150.
Walls, C., Lauby, J., Lavelle, K., Derby, T., & Bond, L. (1998). Exposure to a
community level HIV prevention intervention: Who gets the message. Journal of
Community Health, 23 (4) 281-299.
Warner, L., Newman, D., Kamb, M., Fishbein, M., Douglas, J., Zenilman, J.,D‘Anna, L.,
Bolan, G., Rogers, J., & Peterman, T. (2007) Problems with condom use among
patients attending sexually transmitted disease clinics: Prevalence, predictors, and
relation to incident Gonorrhea and Chlamydia. American Journal of
Epidemiology, 167 (3) 341-349.
Wilson, T., Gore, M., Greenblatt, R., Cohen, M., Minkoff, H., Sliver, S., Robinson, E.,
Levine, A., & Gange, S. (2004). Changes in sexual behavior among HIV-infected
women after initiation of HAART. American Journal of Public Health, 7 (1),
1141-1146.
92
Winningham, A. (2006). Older adults and HIV/AIDS. Rural Center for HIV/AIDS
Prevention. 17, 1-2.
Williams, T., Connolly, J. & Cribbie, R. (2008). Light and heavy heterosexual activities
of young Canadian adolescents: Normative patterns and differential predictors.
Journal of Research on Adolescence, 18 (1), 145-172.
Wu, Y., Burns, J., Santon, B., Li, X., Harris, C., Galbraith, J., & Wei, L. (2005).
Influence of prior sexual risk experience on response to intervention targeting
multiple risk behaviors among adolescents. Journal of Adolescent Health, 36, 5663.
Yarber, W., Graham, C., Sanders, S., Crosby, C. (2004). Correlates of condom breakage
and slippage among university undergraduates. International Journal of STD &
AIDS, 15, 467-472.
Young, R., Kiosses, D., Heo, M., Schulberg, H., Klimstra, S., DeAsis, J. & Alexopoulos,
G. (2007). Age and rating of manic psychopathology. Bipolar Disorders, 9, 301304.
Zaleski, E. & Schiaffino, K. (2000). Religiosity and sexual risk-taking behavior during
the transition to college. Journal of Adolescence, 23, 223-227.
Zekan, S., Novotny, T., & Begovac., J. (2008). Unsafe sexual behavior among HIVinfected patients in Croatia, 2006: Prevalence and associated factors. AIDS
Behavior, 12, 86-92.
Zhao, M., Du, J., Lu, G., Wang, Q., Xu, H., Zhu, M., & McCoy., C. (2006). HIV sexual
risk behaviors among injection drug users in Shanghai. Drug and Alcohol
Dependence, 82, 43-47.