When Two Heads Aren't Better Than One: AIDS Risk Behavior in College-Age Couples1

When Two Heads Aren't Better Than One: AIDS Risk Behavior in College-Age Couples1

JILL C. HAMMER, JEFFREY D. FISHER,^ AND PATRICIA FITZCERALD

University of Connecticut

WILLIAM A. FISHER University of Western Ontario

Individuals in intimate relationships engage in higher levels of HIV risk behavior than do individuals engaging in casual sex (e.g.. Bowen & Michal-Johnson, 1989; Misovich, Fisher, & Fisher, 1996). While there are many possible reasons for this consistent pattern of effects, few studies have focused on identifying the underlying causes. Therefore, same-gender focus groups wcre conducted with college-age men and women in intimate relationships as participants in order to examine, qualitatively, factors particular to relationships which are associated with HIV risk. Focus-group members indicated that concerns about questioning interpersonal trust and commitment in their relationship through the introduction of condoms or HIV testing were often strong impediments to these practices. Recommendations for future HIV-prevention interventions specific to individuals in relationships are discussed.

Although heterosexual college students in general have been shown to be at risk for HIV (Catania, Coates, Greenblatt, & Dolcini, 1989; Fisher & Misovich, 1990; Hansen, Hahn, & Wolkenstein, 1990), those in intimate relationships are especially unlikely to concern themselves with safer-sex practices (e.g., Bowen & Michal-Johnson, 1989; Metts & Fitzpatrick, 1992; Misovich et al., 1996). Along the same lines, Moore and Barling (1991) report that, for heterosexual adolescents, intimacy in a relationship is negatively related to the intention to use condoms, and feelings of liking and romantic involvement are inversely related to HIV preventive behavior (Edgar, Freimuth, Hammond, McDonald, & Fink, 1992). Although heterosexual college students tend to practice serial monogamy (Bowen & Michal-Johnson, 1989) and may be involved with a

'This research was supported by a grant from the National Institute of Mental Health (1-ROI-MH46224-05). The authors wish to thank John Beauvais, Dean Cruess, Stephen Misovich, and Laura Pittman for assistance in the preparation of this manuscript.

ZCorrespondence concerning this article should be addressed to Jeffrey D. Fisher, Department of Psychology, U-20, Room 107, 406 Babbidge Road, [Jniversity of Connecticut, Storrs, CT 06269- 1020. e-mail: j [email protected].

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Journal of Applied Social Psychology, 1996, 26, 5, pp. 375-397. Copyright 0 1996 by V. H. Winston & Son, Inc. All rights reserved.

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number of partners over the course of their college experience, intimate relationships seem to be considered permanent and “safe” while they are occurring, and individuals tend to consider their partners safe with regard to HIV risk (e.g., Hernandez & Smith, 1990; Ishii-Kuntz, Whitbeck, & Simons, 1990; Metts & Fitzpatrick, 1992; Misovich et al., 1996).

This pattern of high levels of risky behavior for young heterosexual individuals in relationships occurs in other populations as well. A study on heterosexual, HIV-infected hemophiliac men shows that couples where one partner is HIV positive and the other is still HIV negative continue to engage in high levels of unprotected sex (Dublin, Rosenberg, & Goedert, 1992), and the same is true of couples where one partner is an HIV-positive injection drug user (Corby, Wolitski, Thorton-Johnson, & Tanner, 199 1 ; Schilling, El Bassel, Gilbert, & Schinke, 1991; Stone, Morisky, Detels, & Braxton, 1989). Gay men in intimate relationships also practice more risky sexual behaviors than do gay men who are not in intimate relationships, believing that being in a relationship will protect them from contracting HIV (e.g., Connell, Crawford, Dowsett, & Kippax, 1990; Offir, Fisher, Williams, & Fisher, 1993). As gay male relationships become more intimate, the likelihood of risky sexual practices increases (Valdiserri et al., 1988).

Although the topic has not yet been subject to empirical research, there are many and varied reasons why people may believe that sex within relationships is “safer” than other sexual encounters, regardless of the type of HIV protection that is being used (Maticka-Tyndale, 1991). Individuals may believe in the safety of relationships because monogamy has been widely purported within the public health establishment as an acceptable form of HIV prevention (Misovich, Fisher, & Fisher, 1993). Unfortunately, it has never been empha- sized sufficiently that serial monogamy (the form of monogamy practiced by many individuals) does not prevent the spread of HIV (Misovich et al., 1993; Reiss & Leik, 1989). Thus, it is still common for many people from varied backgrounds to report that the practice of serial monogamy is a major reason why they do not use condoms (e.g., Offir et al., 1993; Richter, Sy, Mukhtar, & Addy, 1992; Schilling et al., 1991).

Another set of reasons for greater HIV risk behavior within relationships emanates from the functions relationships serve for individuals. Relationship partners provide intimacy and a source of commitment, and constitute important peer referents (Christopher & Roosa, 1991; Fisher & Fisher, 1994). The importance of relationships in fulfilling these functions may inhibit people from making a connection between HIV risk and their relationship partner, because the behaviors which could have caused HIV risk in the partner (e.g., perceived promiscuity, gay sex, injection drug use, “cheating,” etc.) may threaten a partnership which provides for many critically important personal

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needs (Fisher & Fisher, 1994; Sprecher, 1989). In effect, the intimacy provided by a close relationship may be so crucial to both partners that the perception of HIV risk in a partner is lessened or eliminated through the use of cognitive distortion (Fisher & Fisher, 1994; Misovich et al., 1996), because the behaviors which could have caused such risk threaten the very existence of the relationship.

It is also clear that maintaining intimacy is a higher priority for young relationship partners than AIDS prevention (Bowen & Michal-Johnson, 1989; Fullilove, Fullilove, Haynes, & Gross, 1990; Williams et al., 1992). Worry about offending or losing a partner-a concern associated with the introduction of safer-sex practices, because they are thought to imply something negative about oneself or one’s partner-is a primary concern among college students (Harlow, Morokoff, & Quina, 1991; Williams et al., 1992). College student relationships are generally fragile and characterized by intense affect (Bowen & Michal-Johnson, 1989). This motivates college students to consider maintaining their relationship to be a first priority, while HIV risk remains in the background.

Another possible reason for greater HIV risk behavior in relationships is couple members’ use of implicit personality theories, or sets of assumptions about the levels of HIV risk associated with people who have particular personality traits, to make assessments of a partner’s HIV risk (cf. Offir et al., 1993; Williams et al., 1992). Implicit personality theories tend to ascribe low HIV risk to individuals whom one knows, who are liked, loved, or who are associated with other favorable traits (Offir et al., 1993; Williams et al., 1992). In effect, college students appear to use implicit personality theories, rather than direct information about a relationship partner’s HIV status, to make “real-life’’ decisions about whether or not to practice safer sex (Offir et al., 1993; Williams et al., 1992). As a result, it is widely believed by students that it is unnecessary to practice safer sex with a relationship partner who one knows, likes, and trusts (Misovich et al., 1993).

Trust is integral to intimate relationships, and relationship members are highly motivated to preserve the perception of trust (Cahn, 1989; Douglas & Atwell, 1988; Kelley & Burgoon, 1991; Maslow, 1962). In order to preserve mutual trust, individuals may be willing to distort their perceptions of their partners’ level of HIV risk (Offir et al., 1993; Williams et al., 1992). Even simply asking about a partner’s level of HIV risk may be viewed as implying a lack of trust, violating relationship norms about trusting and causing a reduction of intimacy (Bowen & Michal-Johnson, 1989; Fisher & Fisher, 1994). Without full acceptance of the other person, relationships may be judged to be inadequate, and showing concern about HIV may be considered evidence of failure to completely accept an intimate partner (Nadler & Fisher, 1992). It is probable

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that safer sex occurs less often in intimate relationships than in casual encounters in part because in close relationships both partners are extremely concerned about appearing trustful and accepting, and are equally concerned about the extent to which their partner trusts them.

Another difficulty with HIV prevention in intimate relationships is the level of communication involved. Couples often begin having sex before they are emotionally intimate or able to communicate about sex with each other (Breakwell, Fife-Schaw, & Clayden, 1991; Ingham, Woodcock, & Stenner, 199 1; Sorensen, 1973). For adolescents, discussion of contraception prior to first intercourse is unusual (Byrne & Fisher, 1983; Polit-O’Hara & Kahn, 1985). Communication is considered to be a crucial skill in negotiating safer sex (cf. Catania et al., 1989; Fullilove et al., 1990), but adolescent relationships often may not be developed fully enough before intercourse occurs for crucial communication skills to mature. Ingham et al. (1 99 1) have shown that condom use is more frequent in couples who wait longer to have sex, which may be due, in part, to communication skills which develop as the relationship endures.

College students also consider discussions of prior relationships, of extrare- lationship activity, and of conflict-inducing topics in general to be “off limits” in their relationships (Bowen & Michal-Johnson, 1989), which may contribute to a lack of discussion about HIV. Especially in areas which are off limits, relationships and sexual interactions are often characterized by indirect and ambiguous communication, and by indirect information gathering (Williams et al., 1992). Indirect communication and information gathering are inadequate to negotiate condom use and HIV testing-direct communication is necessary for these activities to occur (Cline, Freeman, & Johnson, 1990). While communication between partners may improve enough later in relationships for direct communication about HIV to occur, by that point the people involved may believe that it is already too late-that if one of them has HIV it has been transmitted (Dublin et al., 1992)-or that they already “know their partner” well enough to obviate the need for safer sex (Offr et al., 1993; Williams et al., 1992).

Gender roles within relationships may also inhibit the discussion and practice of safer sex (Whitley, 1988). Gender role socialization, which directs women to be sexually passive, inhibits women’s initiation of sexual behavior and of contraception (Cohen & Rose, 1984; Weatherley, 1987), and promotes the “macho” male sexual role that encourages taking dangerous risks and discourages impulse control (Mosher & Tomkins, 1988), may affect safer sexual practices in relationships. Although certain types of birth control are viewed as within the realm of the female (Cohen & Rose, 1984), sexual decision making in general is considered to be part of the male role (Gerrard, Breda, & Gibbons, 1990), which may confuse male and female college students


in relationships about their roles in initiating condom use, HIV testing, and other safer-sex techniques. Further, men and women may communicate differently about AIDS (e.g., women may speak more directly about HIV risk; Bowen & Michal-Johnson, 1989; Cline et al., 1990), and this may lead to misunderstandings concerning safer sex.

There are many potential reasons why intimate heterosexual relationships among college students might be associated with low levels of AIDS-preventive behavior. While the literature to date has primarily documented the more risky practices of individuals in relationships and suggested a plethora of potential underlying causes, ascertaining empirically the primary factors associated with the more risky sexual practices of individuals in relationships is important since as many as 85% of sexually active college students consider themselves to be in an intimate relationship (Misovich et al., 1996).

In the present research, focus groups were conducted with college students in intimate relationships as participants. Participants were questioned about their feelings and their partners’ feelings concerning condoms and HIV testing, and about how their intimate relationship had affected, or been affected by, initiating or not initiating condom use or HIV testing. Questions were phrased in such a way that the information provided would help to indicate what aspects of intimate relationships influenced couples’ practice of unsafe sex. Based on these findings, it may be possible to begin to design effective AIDS risk-reduction interventions which specifically address the needs and concerns of intimate- relationship partners regarding safer sexual practices.

Method

Participants

Participants were undergraduate students at the University of Connecticut, ranging in age from 17 to 21, who were involved in intimate heterosexual relationships (i.e., monogamous dating situations). Reported duration of relationships ranged from 1 month to 3 years, with the modal length being approximately 5 months. Thirty-four male and 45 female participants involved in such relationships were recruited to participate in same-gender focus groups. Nine female focus groups ranging in size from 4 to 8 participants, and five male focus groups, ranging in size from 5 to 8 participants, were conducted. Partici- pants were asked not to sign up for a focus group in which anyone they knew was already participating. Each participant received experimental credit toward an introductory psychology course requirement for research participation. The study was run over the course of a year, from the fall of 1992 to the fall of 1993.

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Procedure

Focus groups were approximately an hour and a half, on average, in duration. A tape recorder and microphone were utilized to record responses. A researcher of the same gender as focus group participants moderated each focus group, and began by introducing him- or herself and explaining the goals of the group. The moderator and the participants wore name tags to make discussion easier, and the moderator employed a protocol with a list of questions to be asked. The protocol was developed based on prior research, reviewed earlier, which suggested different types of effects that relationships might have on HIV preventive behavior. The focus-group moderator had a degree of freedom to rearrange the questions in the protocol or to ask related questions if he or she thought more information could be gathered in that way, but the questions in the protocol were always asked in approximately the same order. All participants were asked to respond to all questions in the protocol, to the extent that they felt comfortable. It was made clear that any answer to a question was acceptable, that no consensus between participants was necessary, and that the purpose of the discussion was to elicit beliefs and feelings rather than factual information.

Before the focus group began, participants were told that they would be engaging in a discussion about sexual decision making, and they were asked to complete informed-consent procedures which detailed what the study involved. It was explained that participants’ responses to intimate topics would be tape recorded to permit accuracy in response recording, but that only authorized researchers would be permitted to listen to the tapes. Participants were also reminded that their responses to intimate topics would become known to other participants in the group. All participants were asked to sign a form agreeing not to repeat any personal information which was revealed in the course of the discussion, and participants were advised that they should not reveal their full names in order to retain confidentiality.

At the start of the discussion, participants were asked to introduce themselves briefly, and an “icebreaker” conversation was initiated by the moderator. The moderator then began to ask general questions about the type of sexual protection (i.e., condoms or some other form of contraception) that participants used in their relationship, how they had chosen it, and what reasons they had for using it. These questions were asked in a nonjudgmental way in order not to bias responses. For example, subjects were asked “In what way did you choose that form of protection?” and “What reasons did you have for choosing it?,” no matter what type of protection they had used. The answers to these questions also helped to unobtrusively assess participants’ perceived level of HIV risk by determining whether concern about HIV influenced the choice of sexual protection.


A second category of questions asked about participants’ current intimate relationships. In the present research context, an intimate, monogamous relationship was defined as a romantic sexual relationship of any duration, which the participant perceived as exclusive (i.e., neither partner was expected to engage in sexual activity with another partner). Participants were asked about the duration and the actual level of exclusivity of their intimate relationship. Questions were also asked about which partner in their intimate relationship chose their current type of sexual protection, and about how and in what context this issue was dealt with at the dyadic level. For example, participants were asked, “Did you discuss [the form of sexual protection used in your relationship] at all? Who brought it up?” The focus-group moderator then inquired whether participants had ever changed the form of sexual protection in their relationship, and if they had, how that change had affected their relationship in positive or negative ways.

A final set of questions was designed to determine, at a very fine-grained level, participants’ feelings about practices related to HIV prevention in relationships. Participants were asked if they had ever considered asking their partner to use condoms, to be to tested for HIV, or both, and more specifically, whether they had ever considered using condoms until being tested for HIV or being tested for HIV in order to cease using condoms. For each of these questions, participants were asked to describe any concerns, thoughts, or feelings that they had about these behaviors, and how they felt their partner would reactihad reacted to these issues. For example, subjects were asked, “How do you think your partner would react if you asked himiher to use condoms (or to be tested for HIV)?” Subjects were also asked how they would react if their partners asked them to use condoms (or to be tested for HIV). Each subject was asked to respond to each question, even when they agreed with the participants who preceded them.

At the end of the study, participants were asked to brainstorm about ways to convince couples to practice safer sex, and about what would constitute an ideal HIV-prevention intervention for individuals in relationships. Pamphlets containing AIDS information were distributed at the end of this discussion, and the moderator corrected any misperceptions about HIV transmission or prevention that had been expressed by participants, who were then given experimental credit and thanked for their participation.

Results

The analytic procedure used in this study followed Basch’s (1987) approach, which suggests that focus-group discussions should be analyzed by sorting responses into categories to note important themes, and illustrating

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these themes through quotations of typical responses within each category. For purposes of the present research, important themes were generated both by tabulating responses and comments which were made most frequently by participants, and by discussion to consensus among the researchers about the important themes elicited in focus-group discussions. Subject behaviors such as condom use, use of oral contraceptives, and HIV testing were tabulated in order to determine the extent of these behaviors. In order to make interpretation of participants’ behaviors and reasons for behaving in a particular way more straightforward, the percentage of participants who responded in a particular way is indicated in the text which follows. Where percentages are not reported, the term “most” refers to 75% or more of participants, “many” refers to 50% or more of participants, and “some” refers to more than 20% of participants. Only opinions which were indicative of at least 20% of participants have been included in the present report (i.e., if at least 16 participants out of the 79 who participated indicated a certain behavior or belief, it was included in this discussion). It should be noted that reporting percentages of participants’ reasons for their behavior is sometimes difficult because some participants generated more reasons for their behavior than others. When reporting percentages would have been misleading, it was not done, and such exceptions are noted in the text.

Preliminary analyses of focus-group content revealed that all participants were familiar with condoms and HIV testing, and were able to discuss their reasons for using or not using these methods of HIV prevention. The college students who participated in this research were also quite knowledgeable about the transmission and prevention of HIV, and appeared to err on the side of caution when judging which sexual behaviors were risky and which were not. However, cautiousness about perceptions of risk did not always extend to actual behavior. While only about 10% of participants had been tested for HIV, only 52% reported using condoms consistently.

The remaining discussion of the results of this research has been organized around the major themes relevant to couples and HIV. These themes were developed through analysis of the primary concerns identified by participants in our focus groups.

Beliefs About Condoms

Participants viewed condom use within relationships with some ambivalence. While more than one third of participants (i.e., about 30 people) perceived condoms as “safe,” convenient, and easy to use, and believed that condoms were a good form of protection from sexually transmitted diseases (STDs) as well as pregnancy, about half of the participants (47%) believed that condoms


detracted from sensation and spontaneity, and some were concerned that condoms were not reliable and might break. For example, a male participant commented, “It’s a hassle; stopping and starting is a turnoff,” and another parodied an interruption to get a condom, “Excuse me, I have to put on my Trojan.” One female participant commented, “It just doesn’t feel as good,” and another said “You lose spontaneity.” While condom users were more positive toward condoms than were condom nonusers, most participants expressed some negative feelings about condoms.

When queried, approximately half of the individuals who used condoms reported using them primarily as STD prevention, with protection from pregnancy being another major reason. This finding contrasted with previous research (e.g., Baffi, Schroeder, & Redican, 1989; Oswalt & Matsen, 1993; Williams et al., 1992), which implicated pregnancy prevention as the primary reason for condom use among heterosexual college students. It is possible that our findings may reflect an increasing perception of vulnerability to HIV among heterosexual college students as the AIDS epidemic progresses. On the other hand, the particular context of the current study may have encouraged participants to think of condoms in terms of sexual protection, discounting pregnancy prevention as a factor in condom use although it may have been the major concern at the time condom use was initiated.

Although the majority of participants believed that condom use constituted a responsible way to protect themselves and their partners from HIV, participants clearly stated that there were situations under which it was difficult to use condoms with their partner. Circumstances which precluded careful thought, such as use of drugs and alcohol, were cited by 38% of participants overall as making it difficult to use condoms. For men, this number increased to 55%. Also, if condoms were not present, many participants indicated that intercourse might occur without them. This suggests that when couples do not plan ahead and obtain the necessary condoms, condom use becomes less likely. Many participants seemed to dislike the necessity of planning ahead to use condoms; in fact, 40% of participants cited universal availability as something which would make it easier to use condoms. One student commented, “If you run out [before a sexual encounter], what are you going to do?”

Forty-eight percent of the participants were not presently using condoms consistently (though relatively few had been tested for HIV), and many of these participants said that it would be difficult to begin using condoms or to go back to using condoms after not using them. One reason was that participants believed that if they had not been using condoms in their relationship, it was already too late to prevent HIV transmission. “By that time, if she has it, you have it, too,” one subject said after the possibility of resuming condom use was suggested. This belief is problematic because it implies that once risky

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behavior has occurred within a relationship, it is difficult to encourage safer behavior. Nevertheless, almost all participants stated that they would agree to the use of condoms if their partner insisted. Further, many participants who used condoms did not believe that they interfered with sex, and one third of male participants felt that certain types of condom-use contexts (e.g., the woman putting a condom on the man) could even bring the couple closer and enhance sex, because they were considered to be highly arousing. These findings bode well for HIV prevention.

Fifty-two percent of all individuals in our focus groups were using condoms as their primary form of sexual protection at the time the focus group took place. This finding is consistent with some data on condom use among college students (Fisher & Misovich, 1990), but other research has shown even less condom use among adolescents (cf. Catania et al., 1989; Hansen et al., 1990). Forty percent of couples represented in the focus groups were using oral contraceptives as their primary form of protection at the time the focus groups took place, with only a few couples using oral contraceptives and condoms, and one couple using a diaphragm. In general, participants’ choice of a method of sexual protection seemed to occur with only limited discussion, which was initiated by the female partner somewhat more than half of the time. Couples sometimes used condoms without any discussion, and in these cases it was usually (i.e., 65% of the time) the male partner who initiated condom use.

It was common for participants in “long-term” relationships (i.e., relationships lasting more than a few months) to switch from condom use early in the relationship to using the pill as their main form of protection, unless one or both partners had an objection to oral contraceptives. About half of the study participants reported such a change. Condoms were most often used in the beginning of relationships, until partners “knew their partner well” and trusted him or her. One third of participants indicated that they would be most likely to use condoms when they did not know their partner well. “If you don’t know the person, then you’re usually going to wear a condom . . .” was a typical comment from a participant. Forty percent of participants indicated that not knowing someone well was a good reason to use a condom, although personal acquaintance with an individual is clearly irrelevant to that individual’s level of HIV risk.

Switching From Condoms to Oral Contraceptives

Switching from condoms to oral contraceptives seemed to be symbolic and highly meaningful to individuals in relationships. For some, starting to use the pill (and abandoning use of condoms) appeared to indicate an end to worry- ing about cheating, prior partners, or poor communication about sexual protection, and to symbolize the beginning of a trusting and committed long-term


relationship. As one young woman said, “It depends on how serious you are with the person-you really have to trust someone for that [using the pill].” One subject stated that continuing to use condoms in a long-term relationship “almost proves. . . a lack of trust.” Many participants looked forward to the transition from condoms to the pill: “I was glad not to have to use condoms anymore” was a common feeling. Overall, when college student couples switch from practicing safer sex to using forms of sexual protection such as the pill which put them at greater risk for HIV, the primary justification seems to be trust.

Unfortunately, couples’ changing to the pill plays a major role in the failure to practice HIV prevention because use of oral contraceptives reduces motivation to use condoms. Some long-term couples who did not switch to the pill from condoms continued to use condoms because the female partner had had difficulty using the pill. “I don’t like to screw around with my body,” was one woman’s comment, and other participants, female and male, mentioned negative side effects of the pill as a reason for continuing to use condoms. This may indicate that the birth-control pill is perceived as the “standard” for long-term couples, and that condoms are used mainly when specific circumstances “dis- qualify” the use of the pill. Physicians and health educators should make an effort to explain that condoms and the pill serve different functions and are not interchangeable (MacDonald et al., 1990). Physicians should prescribe condoms along with prescriptions for oral contraceptives, and HIV-prevention interventions should emphasize the need to use both the pill and condoms for sexual protection.

Within relationships, one reason for switching from condoms to oral contraceptives without mutual HIV testing to determine the safety of such a switch was a belief by participants that intimate relationships are inherently safe, even though the factors used by couples to judge this safety (e.g., knowledge of the partner, trusting, liking, or loving the partner) are objectively irrelevant to the partner’s actual level of HIV risk. In effect, certain objectively irrelevant characteristics commonly present in close relationships (e.g., partner knowledge, trust) appear to be associated with the belief that condom use is unnecessary (cf. Misovich et al., 1993). A typical comment was “I won’t have sex with someone unless I trust them and know their background.” Partners who are known and familiar are perceived to be safe, and thus to make safer-sex practices unnecessary. One woman said “I went out with my boyfriend from home, so I know who he’s been with . . . ,” and one man said “I know I’m not HIV positive because every girl I’ve been with I’ve known for a little while.”

This type of thinking, which is dangerous because it involves making decisions to practice safer or risky sex based on factors other than one’s own and one’s partner’s actual HIV status, may stem from the advice to “know your

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partner” that has been actively promoted by many health experts (Misovich et al., 1993; Reiss & Leik, 1989; U.S. Department of Health and Human Services, 1988). In fact, no type of partner knowledge other than knowledge of the partner’s HIV status can help protect one from HIV. Nevertheless, the ways in which people in relationships make “real world” judgments about their partner’s HIV risk and about whether to practice safer sex with them are important to understand, because while genuine risk reduction in relationships (i.e., associated with condom use or with mutual HIV testing and monogamy) can help control the spread of HIV, inaccurate perceptions that one’s partner and oneself are not at risk can facilitate the spread of HIV.

An intervention in which both members of a couple participate could provide an occasion for partners to discuss realistically the objective level of risk in their relationship in a safe environment where false perceptions could be corrected (Fisher & Fisher, 1994). Such an intervention would need to thoroughly debunk the myth that knowing your partner’s background, or liking, loving, or trusting your partner eliminates HIV risk (Offr et al., 1993; Williams et al., 1992). Another issue which would need to be addressed with some sensitivity is that individuals in relationships sometimes lie to minimize the extent of their sexual history in discussions with partners (Cochran & Mays, 1990). In the focus groups in our study, large numbers of participants claimed that their partners were virgins or had only been with “one other person” before their current relationship-a far larger number than one might expect, given the age of the participants (Binson, Dolcini, Pollack, & Catania, 1993; Bowie & Ford, 1989; Hansen et al., 1990), and it is likely that minimization of previous sexual encounters might have occurred in “sexual history” discussions between the partners. Since many of our participants based their reasons for not using condoms with their relationship partner on this kind of information, this issue needs to be addressed in HIV-prevention programs.

Perceptions of Risk

Notwithstanding their objectively risky behavior, many statements that participants made suggested that they were concerned about finding a relationship partner who would not infect them with HIV. One woman commented, “I won’t have sex with someone unless I really trust them [not to have HIV].” Unfortu- nately, as noted above, while participants did make an effort to ascertain the “riskiness” of their relationship partners, the factors on which they based these decisions (e.g., the extent of their knowledge of their partner) were flawed. Not surprisingly, the couple members in our focus groups did view having sex with individuals who were not well known as being a risky practice. For example, one woman said “If it’s a one-night stand, you have no idea who this person


has been with. They could have been with a number of people, and you can’t know what you’re getting yourself into.” An unfortunate corollary to this decision rule is that sex with a relationship partner whom one does know is invariably considered to be safe. The pattern of viewing one’s relationship partner as invariably safe but a one-night stand as risky may account for findings that people in relationships are much more apt to use condoms when they have an extra- relationship affair than within the context of their relationship (e.g., Carroll, 1988; Des Jarlais et al., 1987; Ishii-Kuntz et al., 1990; Offir et al., 1993).

Nevertheless, not all participants believed that they had eliminated their risk of contracting HIV from their relationship partner. Many participants acknowledged that they had engaged in risky behavior with their partner, and stated that they did not always think clearly about the issue of safer sex. About 60% of participants felt that strong feelings such as sexual desire for their partner, or concern about offending a partner (e.g., calling into question issues of trust or commitment), were powerful enough to override concerns about AIDS and could lead to unsafe sex. While the perception of risk was present, for many that perception was not acted upon. In the future, couples-level HIV-prevention interventions should deal with relationship partners’ concerns about offending or distancing their partner by requesting safer sex, and should offer means of communication which eliminate these concerns.

Communication

Part of the difficulty in realistically assessing a partner’s level of risk or practicing safer sex with a potentially risky partner is the awkwardness many college student couples feel when conversing about HIV and HIV prevention (Bowen & Michal-Johnson, 1989; Cline et al., 1990). The issues here are many. One third of female and 50% of male participants were concerned that bringing up the subject of HIV or HIV testing is equivalent to accusing their partner of cheating or sleeping around. One participant stated “It’s like you’re saying, ‘I think you’ve slept around’.’’ This belief inhibited frank discussion. Another problem is that discussion of sexual matters often does not begin until partners feel comfortable talking to each other about such topics, and that level of comfort may not be reached until long after a sexual relationship has begun. “We discussed it after the fact,” was one person’s comment. Those people who used no sexual protection at all during intercourse stated that no discussion of sexual protection had taken place-as one woman said, “we just didn’t talk about it.”

Communication may improve somewhat as relationships progress. Never- theless, communication in relationships typically occurs in such a way as to enhance trust, not to undermine it. Conversations which increase certainty

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about the relationship occur, but both partners seek to avoid discussions which decrease certainty and intimacy. One woman succinctly summarized the difficulty with discussing HIV by saying “If you’re not comfortable talking about your basic feelings, you’re not going to say you want an AIDS test.” HIV prevention is seen by many as a betrayal of trust, and this makes it a difficult topic to consider or discuss. “We never, ever talked about it,” one woman admitted, “I don’t think I could ask him.” Even when partners become intimate enough to discuss issues of HIV prevention, they may feel constrained to accept unconditionally everything that their partner says in order to demon- strate their trust. As one participant said, “You do trust that person, and you get to know them, and ifthey say they don’t have it, they don’t have it.” In addition, by the time discussion occurs, the difficulty of altering a familiar pattern of unsafe behavior is often overwhelming.

Within long-term relationships, interventions must change perceptions of talking about HIV by demonstrating that such conversations can increase rather than decrease trust and certainty. Communication between intimate relationship partners is likely to have a different character than communication between people who are casually dating, and long-term couples may need specific kinds of communication skills that indicate mutual intimacy and concern in order to negotiate HIV-prevention arrangements.

Trust in Intimate Relationships

In long-term relationships, trust and intimacy are powerful issues (Douglas & Atwell, 1988). Safer sex may become more difficult because, as a physical and/or symbolic barrier between sexual partners, it seems to imply a lack of trust or intimacy. About 60% of participants made it very clear that if their partner had asked them to use condoms after a period when they had not used condoms or asked them to be tested for HIV, they would be suspicious and mistrustful and would wonder about their partner’s motivation for making such a request. “I’d wonder what he’d been doing” was a comment by one female participant which many other women echoed. “I’d worry that they would think I didn’t trust them” a male participant said when asked if he could make such a request of his partner, and another man, when asked about what he would think if his partner made a request to use condoms, hypothesized, “Maybe she slept with someone else.” Worry about the outcoiiie of this type of request seemed to inhibit HIV-preventive behavior and communication in intimate relationships.

The issue of trust is clearly a paramount concern for college students in intimate relationships, and students in our focus groups seemed to view trust as the measure of whether a relationship was really working, and felt that mistrust


must be avoided at all costs. To the extent that safer-sex is practiced in relationships, it is practiced when the people involved feel that safer sex behavior is indicative of trust and caring: “not just because I’m worried about you [having HIV] but because I’m worried about me [having HIV].” Couple members who expressed sentiments such as “it just makes us closer” about condoms were more likely to take a positive, HIV-prevention approach to sexual relations in general, believing that such an approach showed how much they cared for their partners. However, those people who viewed condom use, HIV testing, and other forms of HIV prevention as a violation of trust or intimacy did not practice safer sex. Instead, they provided various rationaliza- tions for their behavior, such as the lack of spontaneity when condoms are used. Those people who believe that safer sex is an expression of trust and intimacy also complained about the disadvantages of safer sex techniques, but claimed that they are surmountable. One woman described her attitude toward condoms in relationships by saying “We’ve been together for two years, so it’sjust what we do. We don’t think about it much.” Overall, our findings suggest that worries about threatening trust and intimacy are often the real difficulties couples have with safer sex. If this is the case, addressing issues surrounding the physical discomfort associated with condoms may not be productive until issues of dyadic trust and communication are addressed. Interventions with couples which deal with all of these issues at the dyadic level may be especially successful in lowering the prevalence of HIV risk behavior.

HIP‘ Testing

HIV testing, although regarded by many participants as a useful way to protect against HIV, evoked many fears. Only 10% of participants had been tested for HIV themselves, and most (over 75%) had not asked their partners to be tested, although they had often considered it. Again, the issue of trust was important. Some participants were concerned about bringing up the subject of HIV testing to their partners because it might make them feel suspicious or mistrusted-“it’s awkward to ask,” one participant stated. Further, some participants believed that asking a partner to get tested might be regarded as an insult, as if “you’re kind of judging their character.” Other barriers to HIV testing were college students’ fears about protecting their privacy, and about the stress inherent in waiting for the test results. Participants also expressed concerns that HIV testing might lead to perceptions of imbalance in relationships, especially if one partner had had more previous partners than the other. Participants feared that such an imbalance might lead to one partner blaming the other for the necessity of getting tested, for example, one subject imagined saying “We’re getting tested because you ’ve had too many partners.”

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Another concern expressed by fewer than 20% of participants was that testing might be viewed as a sign of “too serious a relationship.” For example, one woman felt that testing had detracted from her relationship because “it made him feel like the relationship was too serious.” While this may suggest that testing could be viewed positively by some because it is compatible with intimacy or serious commitment, it exposes a further difficulty that others may have with testing (i.e., that it may change the status quo of the relationship). To the extent that partners do not wish their relationship status quo to change, they may not feel comfortable with testing (Fisher & Fisher, 1994).

Finally, participants tended to avoid testing because they believed that if either partner tested positive the relationship would end, and this potential loss made HIV testing more difficult. One person said “It’s scary. You don’t want to think of your boyfriend having AIDS. You’re out a boyfriend.”

In spite of these difficulties, over half of the participants felt that being tested for HIV either would not affect their relationship or would change it for the better. As one participant said, “If you both care about each other, it’s not that big of an issue.” Some felt that relationships would become closer as a result of HIV testing, for example, one participant mentioned that mutual HIV testing “would make me more secure and comfortable with [her partner]”. This sentiment was expressed particularly often in the context of both partners being tested, which is encour- aging because it suggests the possibility of linking mutual HIV testing with increasing intimacy in relationships. Increased intimacy is not always desired by both members of a couple, but when it is desired, it may be quite helpful that mutual HIV testing accompanied by monogamy can be viewed as an expression of couple members’ intimacy and commitment to a long-term relationship.

At present, “going on the pill” is viewed as an expression of commitment by couples; perhaps mutual HIV testing and monogamy can also assume such a role in the future. This view of mutual HIV testing and monogamy might make it the logical form of HIV prevention for many long-term relationships. By and large, mutual HIV testing and monogamy were viewed more positively by couples in our research than was condom use, and many participants seemed to consider them a viable option in their relationship, largely because they permitted abandoning condom use, lowered worries about HIV, and allowed more trust and intimacy between relationship partners. While close to two thirds of participants were concerned about confidentiality issues associated with HIV testing, its availability, and especially the tension-filled wait for test results, most felt that the effort to be tested would be worthwhile.

Gender Issues

Although both men and women responded similarly to many of the issues


explored above, they seemed to differ in their opinions on various questions. The fact that discussion of sexual protection was initiated by the female partner somewhat more than half of the time (while condom use without discussion was initiated more frequently by the male) suggests, in accord with previous research (Cline et al., 1990), that women felt more comfortable than did men with communication about safer-sex issues. Men and women also had different ideas about the circumstances that can preclude safer-sex discussions. While a third of women felt that drugs and alcohol might inhibit their ability to discuss safer sex concerns, fully half of men believed this. In addition, women perceived men as relatively more intolerant about safer-sex issues than women.

Both men and women expressed dislike for condoms, but men generated more disadvantages to using condoms than did women, and women expressed more concern that their partner would dislike using condoms than did men. Men tended to dislike condoms because of discomfort, while women tended to describe condoms as more “inconvenient.” Additionally, both men and women noted that negative stereotypes exist about women who carry or possess condoms, and these stereotypes made some women reluctant to carry condoms. This may explain why female participants had obtained condoms for the first sexual encounter of the relationship only one fourth as often as men. Neverthe- less, both men and women agreed that if women would obtain and carry condoms more often, safer sex would occur more frequently. Overall, women and men felt that practicing safer sex in relationships involved confronting rather than avoiding gender differences in sexuality and communication, and this was perceived as a complicating factor. Future interventions with couples might include discussions of common gender differences in these areas, so that heterosexual partners would be better able to understand each other when dealing with HIV.

Discussion

There is still a great deal of risk behavior among individuals in relationships, although the individuals involved generally consider themselves to be relatively safe. Of the many issues discussed above which relate to HIV risk behavior in college student couples, the questions of relationship maintenance and interpersonal trust seemed to be paramount. While issues of communication, concerns about gender roles, and beliefs about the safety of monogamous relationships played a significant role in the practice of risky behavior, individuals were most concerned that HIV-relevant topics such as condoms and HIV testing would violate the trust they and their partners had achieved and would act to threaten their relationships. Preparing couples to deal with HIV in

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a way which enhances rather than threatens trust and relationships may be the most important intervention strategy to follow.

Current research seems to indicate that mutual trust, intimacy, and sharing within relationships are issues so crucial for couples that a danger as large as HIV can be ignored when it threatens these aspects of a relationship (Misovich et al., 1996). This seems to hold for both heterosexual and gay male couples (e.g., Bowen & Michal-Johnson, 1989; Kalichman, Kelly, & St. Lawrence, 1990; Metts & Fitzpatrick, 1992; Offir et al., 1993; Williams et al., 1992), and the same HIV-relevant issues are likely to be problematic across age groups as well-older couples may be facing similar difficulties in HIV prevention. In effect, couples may be quite strongly disposed to reject safer sex practices which are perceived to inhibit intimacy or to violate perceptions of trust.

One way of looking at the present results-and the differences in risky behavior for those who are in intimate relationships and those who are not- involves cost-benefit analyses of risky and preventive behavior (Kirscht & Joseph, 1989; Rosenstock, 1990). From this perspective, individuals who are in intimate relationships clearly have different costs and benefits and different cost-benefit ratios for engaging in AIDS-preventive behavior than those who are not in intimate relationships. For individuals in intimate relationships, the costs of initiating AIDS-preventive behavior are perceived to be very high (e.g., threats to trust or intimacy, the perception that one is revealing something very unfavorable about him- or herself, or accusing the partner of something unfavorable). Further, the benefits of engaging in prevention are perceived to be very low (individuals view it as highly unlikely that someone who is liked or loved and trusted could possibly be HIV positive). In summary, those in intimate relationships believe it is highly unlikely that their partner could be HIV positive, but highly likely that initiating condom use or HIV testing could damage their relationship, which is hardly a favorable cost-benefit ratio.

In contrast, those who are not in an intimate relationship (e.g., individuals having a one-night stand) view the costs and benefits of engaging in AIDS preventive behavior quite differently. For individuals having casual sex, the costs of initiating AIDS preventive behavior are much lower than for those in intimate relationships. Since those having casual sex have little invested in their relationship and derive few critical psychological benefits from it, the costs of damaging it or losing it through the initiation of AIDS preventive behavior are relatively low. Further, the perceived benefits of engaging in AIDS prevention are much higher for individuals in casual relationships. Individuals do believe that the likelihood of contracting HIV is much greater from a casual relationship partner than from an intimate relationship partner (Offir et al., 1993; Williams et al., 1992). Thus, the benefits ofpracticing safer sex in a casual relationship are perceived to be much greater than those in


intimate relationships. Overall, it is quite clear that participants viewed the cost-benefit ratio for protected sex in casual relationships to be much more favorable than in intimate relationships.

Because intimate couples’ cost-benefit ratios for safer sex are less favorable and their levels of HIV risk behavior are greater (e.g., Edgar et al., 1992; Hernandez & Smith, 1990; Misovich et al., 1996; Williams et al., 1992), factors specific to being in a relationship may make intervention approaches which work well with single individuals less effective with people in relationships. Although reducing the incidence of risky sexual behavior among individuals in intimate relationships may be especially difficult, understanding what it is about being in a relationship that inhibits safer-sex practices may make this task possible. Designing interventions to foster HIV prevention in couples should be a priority. Although relationship members tend to see each other through rose-colored glasses, somehow we need to convey the message, as stated by a participant, that “you can trust someone with your heart and still not trust them with your life.”

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When Two Heads Aren't Better Than One: AIDS Risk Behavior in College-Age Couples1

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