Safer Sex in Personal Relationships

The Role of Sexual Scripts in HIV Infection and Prevention

Tara M. Emmers-Sommer, Mike Allen

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781135627706
• Edition: 1
• Topic: Langues et linguistique
• Subtopic: Études sur la communication

This book focuses on safer sex discussion and practice in close, personal relationships, emphasizing research on individuals in personal relationship types that are experiencing a rise in HIV infection and AIDS. Moving beyond studies of gay adult males and IV drug-users, this work paints a clear picture of the very real risk that exists for these less-studied, more general populations, so individuals may better personalize the risk and engage in more preventative measures. Authors Tara M.Emmers-Sommer and Mike Allen examine issues surrounding safer sex, utilizing research that focuses on how individuals struggle with personalizing the HIV and AIDS risk and how they cope with safer sex issues. Safer Sex in Personal Relationships takes readers on a journey through a variety of close relationship types. It begins by highlighting awareness to the global enormity of HIV and AIDS and providing a link between the global and personal, and the need to make HIV and AIDS awareness part of everyday talk and personal relationship structure. It then focuses on:
*safer sex in close relationships, both heterosexual and homosexual;
*marital relationships and the importance of safe sex discussion and awareness in marriages;
*HIV and AIDS from a multicultural perspective;
*HIV and AIDS in aged populations; and
*increasing awareness, understanding, and compassion of those living with HIV and AIDS.This book will appeal to scholars and students concerned with HIV and AIDS in personal relationships. It will be an invaluable text for courses on interpersonal communication and relationships; family, marital, human sexuality, sex and gender, gay and lesbian relationships, and sexual education; and relational conflict across communication, psychology, and sociology disciplines.

CHAPTER ONE
Why Examine Safer Sex in Personal Relationships?

NATURE AND EXTENT OF THE PROBLEM

Approximately 2 decades after HIV and AIDS were originally discovered in 1981, 40 million individuals worldwide are living with HIV. Seventy percent of these individuals are Africans (World Health Organization [WHO], 2002). AIDS is the leading cause of death in Africa and the fourth leading cause of death universally (WHO, 2002). Within the United States, 774,467 individual cases of AIDS were reported to the Centers for Disease Control (CDC) between 1981 and 2000. Eighty-three percent of these cases involved men and 17% involved women. Of the 774,467 cases reported to the CDC, 448,060 of these individuals have perished (CDC, 2002). Until an effective vaccination program or curative treatment is developed, the numbers are expected to continue to increase. The worldwide implications of this growing problem are increasing as the Indian subcontinent (in late 2002 the estimate was over 4.5 million infected with an expectation of 25 million by the year 2010, Milwaukee Journal, 2002), the old Soviet Republics, and mainland China start to experience increases in infection. The full level of economic disruption and social dislocation from millions of AIDS orphans and loss of economic potential occurs. The evidence, particularly in Asia, is for a growing and impending crisis in the future that continues to intensify and become increasingly disruptive.

Over the past 2 decades, the media and much research have heavily focused on certain groups (e.g., gay and bisexual men, intravenous (IV) drug users, prostitutes) when examining HIV and AIDS. Indeed, at the onset of HIV and AIDS in the United States, the predominant groups afflicted by HIV and AIDS were men having sex with other men and intravenous drug users, particularly the former (CDC, 2002). Trends over the past 15 years, however, indicate a decrease in AIDS among men having sex with men and a plateauing of cases among IV drug users. A marked increase in trend, however, exists for individuals diagnosed with AIDS due to heterosexual contact. In fact, in 2000, the individuals diagnosed with AIDS due to IV drug use and heterosexual contact were the same (i.e., 27%) (CDC, 2002).

Until 1985, the CDC had to rely on state reporting of AIDS cases for AIDS surveillance purposes. Due to the effectiveness of antiretroviral drug therapies for individuals afflicted with AIDS, the AIDS epidemic appeared to be quelling as AIDS trends no longer represented HIV incidence. As a result, it became necessary for states to instill confidential HIV case surveillance; thus, states reported AIDS and HIV cases, rather than only AIDS cases, to the CDC (CDC, 2002). The CDC cautioned that the confidential HIV surveillance incidence reportings are underestimates of the real rate of infection. Specifically, as of June 2001, approximately 14 states still did not participate in confidential HIV surveillance. Some of these 14 states include large populations and metropolitan areas (e.g., California, Maryland, Hawaii, Washington State, Illinois). Two states participated in pediatric HIV reporting only (Connecticut and Oregon) (CDC, 2002). Indeed, the scope of the problem is immense. A variety of pathways exist that enable a person to become HIV positive. The following section focuses on HIV transmission and its effects.

Transmission of HIV

Fluids. HIV can be transmitted in a number of manners. According to the CDC (2002), HIV can be passed through blood, semen, pre-seminal fluid, vaginal fluid, breast milk, or other bodily fluids containing blood. More specific to health care workers, the virus may also be passed via amniotic fluid supporting a fetus, synovial fluid around bone joints, and cerebrospinal fluid surrounding an individual’s brain and spinal cord. The popular implication of this means of transmission is that HIV is not passed through “casual” contact or by someone just coughing or sneezing. HIV transmission requires contact with body fluids in a manner that permits entry into another person.

Modes of Entry. Information from the CDC indicates that HIV can enter the body through a number of areas including the anus, rectum, vagina, penis, mouth, veins (e.g., IV drug use), and other mucous membranes (CDC, 2002). This requirement for HIV transmission further reduces the expectation that casual contact will result in infection. The restricted means of entry makes HIV transmission usually linked to very identifiable and specific behaviors.

Behaviors Encouraging Transmission. Typically, HIV is transmitted by: (a) engaging in anal, oral, or vaginal sex with an HIV-infected individual, (b) sharing needles or other types of injection materials with an HIV-infected individual, and (c) HIV-infected mothers transmitting the virus to their baby before, during, or after birth (e.g., via breastfeeding). Although far less likely, HIV can be transmitted through contaminated blood transmitted via blood transfusions or needle-sticking, which is more specific to healthcare workers (CDC, 2002).

HIV’s Transformation to AIDS. According to the CDC (2002), about half of the individuals who are infected with HIV will develop AIDS within a 10-year period. A variety of factors influence the effects of HIV in the body, including the individual’s engagement in further risk behavior, engaging in preventative care, medical treatments, and so on. Clearly, HIV and AIDS awareness and education are important elements to individuals’ understanding, communication, and behavioral modification. The following section addresses these issues within the context of managing HIV and AIDS in the future.

HIV AND AIDS: WHAT THE FUTURE HOLDS

According to the World Health Organization (2002), 15,000 individuals become infected with HIV daily and 95% of these cases are in developing countries. The World Health Organization contended that an AIDS vaccine is the most promising long-term solution to the HIV/AIDS epidemic, particularly in developing countries. As of yet, however, no vaccine exists, and the expectation for the development of a vaccine or curative treatment, although hopeful, does not appear immediate. Clearly, these data and information suggest that HIV and AIDS are of public concern. We contend that these data are also of personal and relational concern. Indeed, (lack of) communication about sexual activity involves both personal and relational implications. In a word, interpersonal communication is a health-related activity. That is, the nature of our communication affects our emotional, mental, and physical well-being. Currently, our strongest weapons against HIV infection involve knowledge, communication of that knowledge, and behavioral adherence to the safer sex practices espoused by the knowledge; that is, practicing interpersonal sexual scripts that encourage safer sex behaviors. The purpose of this book is to address safer sex issues in personal relationships. The following sections lay the definitional and theoretical groundwork. The theoretical framework offered in this chapter serves as a guide as the acquisition and evolution of scripts are discussed throughout the remainder of the text as they apply to a variety of personal relationship contexts. To begin, safer sex is defined.

DEFINITIONAL FRAMEWORK

We define safer sex as a description of any action a person takes to diminish the level of risk for HIV infection. Most frequently, the term is used to describe the use of a condom during sexual behavior to prevent contact with bodily fluids. However, there are a variety of practices that would be “safer” when compared to others. For example, instead of anal sex, a gay male couple could engage in sex using their hands (e.g., mutual masturbation). Performing oral sex, although believed to carry some risk, is “safer” than vaginal or anal sex. modification or avoidance of some types of sexual acts would reduce the level of risk. Another method of reducing risk from sexual contact would be a reduction in the number of sexual partners (an exclusive mutually monogamous relationship between HIV-negative persons would carry virtually zero risk of infection). Avoiding persons with a history of intravenous drug use or a sexual history of unprotected and/or commercial sex reduces risk. These risk factors however require that the person ask or discuss with the potential partner as well as honestly disclose these facts about him- or herself. For many persons, discussion of the number of type of prior sexual acts with someone other than the current partner is generally considered inappropriate. This conversational topic, or the desire to have this conversation, for many persons would be considered a violation of the normal expectations about the script of sexual behavior between individuals. Many persons either do not want to hear and/or do not want to disclose this information to the other person. In fact, deception about the disclosure is not uncommon because of the fear that disclosure of information would diminish the possibility of sexual behavior with a partner (Lucchetti, 1998).

Overall, however, it is necessary to be mindful of the fact that none of these risk-reduction techniques are foolproof. Condoms break, fluids spill, sores bleed, and partners can lie or mislead about their personal practices. The only true “safe sex” is masturbation or abstinence. Given the low probability of that event taking place for a variety of social and personal reasons, the only recourse is some form of education and prevention that reduces the risk as much as possible for sexually active persons. The goal ought to involve the production and adoption of conversational strategies that become ingrained or accepted behavioral routines that involve safer sex. The goal of educational programs should be the installation of these routine patterns of behavior that are associated with safer sexual practices.

The primary theoretical framework guiding this project is script theory from a sexual, developmental perspective (Metts & Spitzberg, 1996; Simon & Gagnon, 1984, 1986, 1987). Specifically, we examine the sexual lifespan of individuals, beginning with adolescence and continued through later adulthood, and how the form and function of sexual scripts throughout the sexual lifespan are reshaped and renegotiated. This view of human interaction is associated with generalized approaches to communication that assume that humans develop scripts or schema (Mandler, 1984). The development of scripts is associated with theories relating to how persons develop a dynamic memory to handle and structure events and processes (Schank, 1982). The various manifestations of these approaches have become MOPs (memory organization packet, Kellermann, 1991), addressed through action assembly theory (Greene, 1984), or accounts (Schönbach, 1990). Each of these approaches examines the nature of how various interpersonal communication interactions are associated with the development of routines to handle the task. The work involves recognizing the situation and then employing the appropriate behavioral sequence to accomplish the appropriate communicative task in the situation.

Within this overarching set of theoretical frameworks are various approaches explaining human behavior that include some aspect of risk personalization (i.e., social learning theory, social exchange theory, personal motivation theory, social identity theory, uncertainty reduction theory, positive outcome value theory, expectancy violation theory, health belief model). This text incorporates recent research (e.g., Crowell & Emmers-Sommer, 2001) examining HIV positive individuals’ attitudes, communication, and behaviors prior to and since their seropositivity, to establish sexual scripts in which safer sex discussions and practices are more conducive. A variety of communities exist that can be examined as they relate to the HIV/AIDS phenomenon. Some of these communities include lesbians, the mentally ill/retarded, the homeless, illegal aliens, minority populations, intravenous drug users, adolescents, commercial sex workers, gay males, and pregnant women. For the purposes of this book, the focus is personal relationships and how scripts are enacted and developed for individuals. However, a variety of sources of support exist that are available to various communities affected by HIV/AIDS. These sources of support include religious personnel, peers, family, and community leaders. Given that the focus of this text is on personal relationships, the following section addresses the na ture of sexual scripts manifested in personal relationships.

SEXUAL SCRIPTS

Despite the statistics, most individuals still tend to perceive themselves as invulnerable to acquiring HIV or AIDS when compared to others (e.g., Raghubir & Menon, 1998). Within the context of close, personal relationships, the discussion and practice of safer sex is often perceived as unnecessary or as violating the expectations, assumptions, or script of the negotiated relationship (e.g., Crowell & Emmers-Sommer, 2001; Willing, 1994). yet, it is at the close, interpersonal level between partners where such discussions and negotiations become most necessary. Sexual interaction remains something negotiated between individuals based on the notions of appropriateness brought into the situation (as well as the previous experience of both individuals with each other as well as previous encounters). Shimanoff (1980) points out that each participant brings to the encounter a set of rules or expectations about the nature of how any communication episode should take place. Each individual evaluates the behavior in the interaction and compares the conversation and actions to previous behavior. If a person acts inappropriately or strangely, the sexual encounter may be interrupted or terminated and each person unhappy with the outcome or consequences. Each person is under a bit of stress or tension to make the conversation fall within the expectations of the other person.

Thus, the purpose of this book is twofold. One purpose is to focus on safer sex discussion and practice in close, personal relationships. A second purpose is to focus on close, individuals in personal relationship types who are experiencing a rise in HIV infection and AIDS but are not receiving as much scholarly research attention as gay and bisexual adult males and IV drug-users. A goal of the book is to paint a clear picture of the very real risk that exists for these less-studied populations so that individuals may better personalize the risk and engage in more preventative measures. Specifically, research suggests that once individuals personalize the risk of HIV, there is an increased chance that they will change their attitude and engage in safer sexual behaviors (Ehde, Holm, & Robbins, 1995; Ishii-Kuntz, Whitbeck, & Simons, 1990; Raghubir & Menon, 1998; Timmins, Gallois, McCamish, & Terry, 1993). We propose to examine safer sex, primarily relying on research focusing on how individuals in the various aforementioned populations struggle with personalizing (or seek to avoid personalizing) the HIV and AIDS risk and how they cope with safer sex issues.

Individuals acquire sexual scripts in a variety of manners. For example, the role appropriateness of gender behavior is related to exposure to the media (Herrett-Skjellum & Allen, 1996). The search for role models and routines that are appropriate in a sexual encounter will reflect one particular source of information, the media. For many college students a major source of information about sexuality is pornography (Duncan, 1990; Duncan & Donnelly, 1991; Duncan & Nicholson, 1991), which typically does not include depictions of condom use. In addition, and as illustrated throughout the remainder of this book, individuals’ sexual scripts evolve over the course of the lifespan. The role of sexual scripts in safer sexual behavior is a very salient one, as it affects safer sex practices (e.g., Hynie, Lydon, Coté, & Wiener, 1998; Maticka-Tyndale, 1991) and perceptions of susceptibility (Maticka-Tyndale, 1991). Sexual scripts have been described as cognitive structures that guide sexual behavior (Metts & Spitzberg, 1996) as well as stereotypical, expected, interactive behavior in social interactions (Abelson, 1981). In summary, sexual scripts serve as a mental roadmap, if you will, for how individuals are to conduct themselves in sexual situations. Sexual scripts are influenced at a number of levels, including cultural, interpersonal, and intrapsychic levels (Simon & Ganon, 1984, 1986, 1987). Interrelationships exist among the levels. Each of these three levels is examined further next.

Cultural Scripts

Cultural scripts are the most broad of the three levels of sexual scripts. Cultural scripts involve overall maps of sexual behavior at the societal level. In a word, cultural scripts address the “who, what, when, and where” aspects of sexual activity. Specifically, cultural scripts involve assessing who is appropriate to desire and pursue sexually, the accepted type of relationship between sexual partners, when and where partners should engage in sexual activity, and how partners are supposed to be feeling in regard to the sexual activity. These various structures contribute to how individuals are supposed to act and how they are supposed to interpret their experiences (Simon & Ganon, 1984, 1986, 1987). Cultural scripts provide a strong sense of social appropriateness or guidance about what “ought” to occur. One example of the impact of social scripts is the difficulty that homosexual parents have in obtaining custody of children and/or visitation rights. Despite clear empirical evidence summarized in a meta-analysis (Allen & Burrell, 1996, 2002), the fear of the violation of social scripts keeps biological parents that are gay away from their children.

Cultural scripts are largely influenced by the media (Metts & Spitzberg, 1996). This point is particularly salient to the context of this book, as young adolescents who are beginning to learn about sex and sexuality are likely to rely on media as a predominant source of information. A study conducted by Strasburger and Donnerstein (1999) found that children and adolescents relied heavily on television and other forms of media to learn about sexuality. In fact, as children enter adolescence, their primary source of information regarding sex, violence, and drugs changes. Specifically, a study conducted by the Kaiser Family foundation in conjunction with Family Circle magazine found that children aged 10 to 12 relied on mothers most often for information on sex, drugs, and violence. Children aged 13 to 15 relied on friends most for information on these topics and mothers as a source of information fell to fifth place. Overall, however, children between the ages of 10 to 15 relied on the media second most often for information regarding sex, drugs, and violence (Ebron, 1999). These findings suggest that children and adolescents rely heavily on media for sources of information on sex, drugs, and violence. In addition, consideration of a parent as a source of information diminishes as children enter adolescence and reliance on peers for information increases (Mazur, 2001). This finding is of potential concern as peers might be misinformed about sex, drug, or violence issues and the media’s representation of these issues is not necessarily realistic or accurate. The type and tone of the media information gleaned by young adolescents greatly varies, from realistic, educational fare to violent or fantasized images portrayed through pornography. For example, Brown and Bryant (1989) found that the majority of females and males had seen or read Playgirl or Playboy by the age of 15. Allen, Emmers, Gebhardt, and Giery (1995) found that some media images portrayed through pornography suggest the acceptability of violence and coercion (e.g., rape) in an effort to gain sex. Portrayals of traditionalism and male dominance can affect men’s and women’s ideologies and scripts about what they are supposed to do in sexual situations versus what they might want to do (e.g., Byers, 1996; Emmers-Sommer, 2002; Emmers-Sommer & Allen, 1999). Other media images (e.g., television shows, movies) rarely include a discussion or use of condoms prior to engaging in sexual activity. This is concerning given that many adolescents coming into puberty receive information about sexual behavior from sources that involve misrepresentation, inaccuracies, or glorification of violence. In that context, the script for sexual behavior will not involve a consideration of the other person or of the need for safer sexual behaviors as a means of disease protection.

Intrapsychic Scripts

Intrapsychic scripts involve “individual desires, motives, and actions that create and sustain sexual arousal” & Spitzberg, 1996, p. 52). Hynie et al. (1998) argued that “intrapsychic scripts are the internalization of the socially shared scripts and scenarios. Social competence requires social performance of cultural scenarios which, in turn, requires rehearsal of interpersonal scripts based on those scenarios” (p. 2). Hynie et al. (1998) also argued that the internalization of intrapsychic scripts plays a...