Accounting for Unsafe Sex: Interviews With Men Who Have Sex With Men

Journal of Sex Research, Feb, 2000 by Barry D. Adam, Alan Sears, E. Glenn Schellenberg

Educational campaigns designed to increase awareness of AIDS and safe sex practices have made a remarkable impact.(1) National populations as a whole, and gay men in particular, are now highly knowledgeable about the ways in which HIV can be transmitted (e.g., Jadack, Hyde, & Keller, 1995; Lewis, Malow, & Ireland, 1997; Myers, Godin, Calzavara, Lambert, & Locker, 1993; O'Donnell, San Doval, Vornfett, & O'Donnell, 1994). Many gay men have managed to integrate safe sex into their everyday lives (e.g., Ekstrand & Coates, 1990; Hunt et al., 1993), yet this change remains incomplete (e.g., Gruer & Ssembatya-Lule, 1993; Hunt et al., 1993; Kelly et al., 1995; Meyer & Dean, 1995; Offir, Fisher, Williams, & Fisher, 1993; Perkins, Leserman, Murphy, & Evans, 1993; Peterson et al., 1992). Whereas some gay men occasionally relax the safety standards that usually govern their sexual activities, others have never adopted safe sex to a great degree. Because the prevalence of HIV-infection in the Western world remains higher among men who have sex with men than among any other segment of the population, unsafe male-to-male sex continues to pose a major public-health challenge.

Much of the research on safe sex education has focused on the association between knowledge about AIDS and sexual practices (see Joffe, 1996; Kippax, Connell, Dowsett, & Crawford, 1993). In the initial phase of the epidemic, primary concerns included tailoring educational programs to specific high-risk populations (e.g., gay men, injection-drug users), and identifying those who were undereducated about AIDS. A central assumption of this approach was that information would shift attitudes, which, in turn, would lead to changes in behavior. As Kippax et al. (1993) remark,

   The dominant model of health education that has been adopted by many AIDS
   researchers, particularly in the United States, is a refinement of what
   might be called the KAP (or KAB) model--knowledge, attitudes, practices (or
   behavior). The KAP model is a linear one, which initially assumed that
   knowledge shapes or determines attitudes which, in turn, shape or determine
   behavior. (p. 5)

As levels of knowledge and awareness about AIDS rose rapidly in many countries throughout the 1980s, it became increasingly clear that rates of safe sex practice often failed to keep up. For example, in one study (Fisher, Fisher, Williams, & Malloy, 1994), a KAP model accounted for 35% of the variance in gay men's AIDS-preventive behavior. Although this association is relatively strong in social-science research, it should not go unnoticed that almost two thirds of the variance could not be attributed to individual differences in knowledge of HIV transmission. Indeed, as people in the European Union, North America, and Australia became increasingly knowledgeable about the basic facts of how HIV is spread, the attention of researchers turned toward the gap between knowledge and behavior (e.g., Catania, Kegeles, & Coates, 1990; Waddell, 1992), which tends to be particularly large for heterosexuals (Maticka-Tyndale, 1992; Maxwell, Bastani, & Yan, 1995; Maxwell & Boyle, 1995).

Accordingly, issues of compliance and relapse in terms of conformity to safe sex norms came to dominate the agendas of many researchers, who asked why people "who know better" still have unsafe sex (e.g., Adib, Joseph, Ostrow, & James, 1991; Kelly et al., 1991; McCusker, Stoddard, McDonald, Zapka, & Mayer, 1992; see Hart, Boulton, Fitzpatrick, McLean, & Dawson, 1992, for a review and critique). This approach attempts to identify factors that compromise rationality, the assumption being that rationality would win out if these factors were eliminated (Hart et al., 1992). Perhaps the factor most commonly identified as an impediment to safe sex is substance abuse (Ekstrand & Coates, 1990; Kalichman et al., 1994; Leigh, 1990; Lewis & Ross, 1995; Meyer & Dean, 1995; Paul, Stall, & Davis, 1993; Penkower et al., 1991; Peterson et al., 1992; Siegel, Mesagno, Chen, & Christ, 1989; Waddell, 1992). Nonetheless, results from studies conducted in the United Kingdom (Weatherburn et al., 1993), the United States (Temple & Leigh, 1992), Australia (Gold, Skinner, & Ross, 1994), Belgium (Bolton, Vincke, Mak, & Dennehy 1992), and Canada (Myers et al., 1992) raise questions about the reliability of this finding.

The "rational man" approach also tends to equate all homosexual practices with high levels of risk, presuming that the simple intervention of the condom suffices as the technique for HIV prevention in all circumstances. Prevention strategies that advocate using a condom every time are consistent with this approach. We know, however, that many male-to-male sex practices carry no risk of transmitting HIV (e.g., mutual masturbation), whereas others have negligible (e.g., anilingus) or low (e.g., receptive fellatio) risk (McClure & Grubb, 1999). Even unprotected anal intercourse carries no risk of transmitting HIV if neither participant is infected with HIV. Traditional KAP and rational-man models also fail to provide a clear understanding of how AIDS messages interact with the meanings and reasoning that homosexually active men use in understanding and expressing their sexuality (Adam, 1992; Donovan, Mearns, McEwan, & Sugden, 1994; Dowsett, 1996; Flowers, Sheeran, Beail, & Smith, 1997; Joffe, 1996; King, 1993; Kippax et al., 1993; Parker & Carballo, 1990). In fact, such models--in combination with discourse about "gaps," "relapse," and so on--tend to gloss over the ways in which standards of practice for safe sex are often provisional and inconsistent.