Harming the Ones We Love: Relational Attachment and Perceived Consequences as Predictors of Safe-Sex Behavior
Afifi, Walid A., The Journal of Sex Research
Since the discovery of HIV in the early 1980s, several hundred studies have been conducted to address the predictors of condom use, and an equally large number of education programs have been implemented to increase the use of condoms. As a result, a recent report from the Centers for Disease Control (CDC) showed a stabilization in the overall rate of growth in HIV infection (e.g., a drop in the annual rate of increase from 60% to 95% in the mid- to late-1980s to approximately 5% annually since 1992) and predicted that this rate will continue to decline (CDC, 1997). Despite these promising trends, other data suggest less reason for optimism. First, the frequency of condom use remains disturbingly low. For example, Bajos et al. (1994), in an international study of safe-sex behavior, found that only 40% of men and 20% of women consistently used a condom with casual sexual partners in the 12 months before the study, and only 57% of men and 44% of women reported having ever used a condom. Second, optimism regarding an overall stabilization in the rate of growth masks data showing dramatic increases in the rate of infection for certain populations. For example, the CDC report (CDC, 1997) and an analysis of those data reported by Wortley and Fleming (1997) showed a large increase in the incidence of HIV infection in young heterosexual women. Specifically, women accounted for 19% of the HIV cases reported in 1995 as opposed to 7% of cases reported in 1985, and there was a six-fold increase between 1991 and 1995 in the incidence of AIDS among women. These data imply the need to critically examine the research literature for biases that may have limited the success of extant research in explaining condom use. A close inspection of extant literature reveals a glaring omission in most efforts to understand safe-sex behavior.
Hall (1990), expressing frustration over the relatively low frequency of condom use, succinctly writes, "Given the extremities of AIDS--that it, as yet, is invariably fatal, that this plague carries an unprecedented social stigma, and that it is an especially gruesome way to die--why ... do people continue to run the risk of contracting AIDS, especially by not using a device as simple and generally available as the condom, a device which the medical establishment validates ...?" (p. 23-24). Although early scholars assumed that such seemingly irrational behavior must be due to a lack of knowledge regarding the AIDS virus and its methods of transmission, a litany of studies have shown that knowledge, in and of itself, is a poor predictor of condom use (for review, see Becker & Joseph, 1988; Geringer, Marks, Allen, & Armstrong, 1993). Instead, scholars have argued that condom-use decisions are influenced by the same conditions that shape individuals' decisions to smoke, diet, and engage in other health-related behavior. Namely, individuals will engage in such behavior if they have a positive attitude toward the behavior, trust that they are capable of performing the behavior, and believe that respected others endorse the behavior (for review, see DiClemente & Peterson, 1994). While the specific operationalizations differ according to the chosen theoretical perspective, attitudes, subjective norms, and self-efficacy generally form the foundation underlying predictions of safe-sex behavior in most studies.
However, more than most health behavior decisions, the commitment to use a condom is a decision that requires dyadic negotiation and cooperation (Metts & Fitzpatrick, 1992). As such, it involves unique interpersonal challenges that complicate its implementation. Central to this negotiation, yet mostly ignored by scholars, is the social meaning given to condoms. Underlying the majority of research on condom use, and apparent in Hall's (1990) question, is the assumption that condoms are devoid of social meaning. Researchers recognize that individuals may perceive condoms to be uncomfortable, clumsy, and impractical (all factors that influence the attitudinal component), but assume that condoms are symbolically neutral objects. …