Harming the Ones We Love: Relational Attachment and Perceived Consequences as Predictors of Safe-Sex Behavior

Journal of Sex Research, May, 1999 by Walid A. Afifi

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. In contrast, this investigation starts with the assumption that condoms carry significant social meaning that may strongly impinge on an individual's decision to request that a condom be used. Understanding these meanings may help explain individuals' seemingly irrational behavior.

THE SOCIAL MEANING OF CONDOMS

A growing body of qualitative research suggests that condoms are imbued with meanings that are threatening to the identity of both partners, as well as to the sanctity of their relationship (e.g., Lupton, 1994; Sobo, 1995). Although mostly unrecognized in research on condom use, the importance of impression management and relational maintenance as individual goals has received considerable attention in other areas of research.

The Importance of Impression Management

Leary and Kowalski (1990) note that "people have an ongoing interest in how others perceive and evaluate them" (p. 34). Hence, they often engage in goal-directed activity in which they seek to shape the impression forged by others, thereby increasing the likelihood that their desired social outcomes will be achieved (e.g., Goffman, 1959). This interest in molding others' impressions of us, otherwise labeled impression management (Tracy, 1990), self-identification (Schlenker, Britt, & Pennington, 1996), or face-work (Cupach & Metts, 1994), is pervasive and has repeatedly been shown to directly influence behavioral choices. For example, Pliner and Chaiken (1990) found that concerns with impression management led individuals to eat less when they were with members of the opposite sex than when they were with same-sex individuals. Further, Robinson and Smith-Lovin (1992) noted that individuals choose interaction partners based on identity needs, Shimanoff (1985) found that the disclosure of emotions in close relationships is partly shaped by impression management concerns, and Holtgraves (1988) argued that gambling enthusiasts are often attracted to wagering because of the opportunity it provides to present a desired identity. Although these studies make up only a small portion of the literature on impression management, they adequately demonstrate the role that it plays in shaping the most mundane to the most extraordinary of human activities.