Communication of sexual risk behavior among late adolescents. (includes commentaries and author's response)

Despite the rise of sexually transmitted diseases (STDs) and HIV infection, young men and women continue to engage in sexual risk behavior (Centers for Disease Control [CDC], 1993). The literature suggests that adolescents who do not discuss sexual risk behavior and who do not negotiate sex-related disease prevention with their sexual partners are putting themselves at risk for unintended pregnancy and STD/HIV infection (Lear, 1995; Rickman et al., 1994; Wenger et al., 1992). Existing research, however, does not provide details about the nature of communication among adolescent sexual partners. Understanding circumstances that facilitate or hinder discussion about sexual risk behavior is essential for developing relevant nursing strategies to promote effective communication and sex-related prevention between adolescent sexual partners. Therefore, the purpose of this study was to describe how males and females in late adolescence perceive communication about sexual risk behavior with their sexual partners.

SEXUAL RISK BEHAVIOR

The incidence of STDs has risen among adolescents more rapidly than in the general population. Two thirds of all cases of STDs occur among people younger than 25 years old (CDC, 1993). Some STDs are more prevalent in adolescents than in older women. For example, adolescent females, aged 15 to 19, have the highest rates of gonorrhea among all women (936.4 per 100,000) (CDC, 1993). The CDC estimates that 3 million adolescent men and women contract an STD annually, accounting for 25% of all new cases each year (CDC, 1993). Because of the high incidence of STDs among adolescents, they are more likely to have sexual partners with an STD than are adults, even if the adolescent has had only one partner (Kost & Forrest, 1992). The number of cases of AIDS among people aged 24 and younger has also increased. Heterosexual contact is the leading cause of AIDS among women aged 13 to 24 (CDC, 1993). For those 20 to 24 years old, there has also been an increase in the number of cases due to heterosexual exposure, which suggests that many of these cases were infected with HIV as adolescents. Given the long incubation period of HIV, many of the 20- to 24-year-olds with AIDS were probably infected as teenagers (CDC, 1993).

Adolescent women who initiate sexual intercourse at an early age acquire multiple partners more rapidly in the first years after intercourse than do young women who initiate sexual intercourse later (Kost & Forrest, 1992). About one third of adolescent women report having had two to three sexual partners. The proportion of adolescent women who report having four or more partners has increased from 14% in 1971 to 31% in 1988 (Kost & Forrest, 1992). Despite the media's focus on AIDS and safer sex, the average number of sexual partners has increased for adolescent males and females. In addition, adolescents often practice serial monogamy, where they are each faithful to one partner until the relationship ends and then move on to a sexual relationship with another partner (Alan Guttmacher Institute [AGI], 1994).

Although adolescents are knowledgeable about AIDS (Keller et al., 1991), they continue to engage in high-risk sexual behavior. As adolescent men grow older, they rely less on condom use and more on female methods, such as oral contraceptives (Ku, Sonenstein, & Pleck, 1993). Furthermore, once adolescent women begin taking oral contraceptives, most do not use condoms consistently (Weisman, Plichta, Nathanson, Ensminger, & Robinson, 1991).

Despite the rising incidence of STDs and HIV among adolescents, their egocentric thought may lead them to perceive that they are at low risk for acquiring STDs or HIV (Poppen, 1994), This perception may lead to inconsistent use of condoms, as well as lack of communication with sexual partners about sexual risk behavior (Overby & Kegeles, 1994).

COMMUNICATION WITH SEXUAL PARTNERS

Assertiveness has been suggested as being an important component of effective communication between sexual partners; however, little research exists on the relationship between assertiveness and sex-related disease prevention. Existing research has demonstrated inconsistent findings. In a sample of 60 college women, no significant relationship was found between assertiveness and using effective contraception (Hughes & Torre, 1987). In contrast, a study of 253 undergraduates found a moderate correlation between assertiveness and safer sex practices (Yesmont, 1992). Women's assertiveness was significantly associated with being cautious about with whom they had sex, asking questions about previous sexual history, and using condoms (Yesmont, 1992). The moderate correlation between assertiveness and safer sex practices, however, suggests that multiple factors may account for the variance in safer sex behavior.

In a comparison of changes in sexual behavior and communication over a decade, Poppen (1994) surveyed college students at a mid-Atlantic university in 1979 and again in 1989. Condom use increased, but discussion of contraception did not increase over the decade. In each time period, about half of the respondents reported having discussed contraception with their current partners. Women were more likely than men to discuss contraception with their sexual partners.

A survey of 427 undergraduates examined the prevalence of disclosing previous sexual risk factors to current sexual partners (Desiderato & Crawford, 1995). Sexual risk factors included multiple sexual partners, not having used condoms in previous sexual relationships, having had an STD, and being HIV positive. About half of the sample did not discuss prior sexual relationships with their current partners, and more than half did not inform their current partners that they had failed to use condoms with previous partners. In addition, one third of the sample did not discuss previous STDs with their current partners. Perhaps the most surprising finding was that 2 of the 12 respondents who had been diagnosed as being HIV positive did not tell their current partners before having sexual intercourse.

Cline, Johnson, and Freeman (1992) explored the role of interpersonal communication in AIDS prevention among 588 undergraduate men and women. The researchers analyzed written responses to open-ended questions about AIDS-related communication issues. Participants were categorized into four groups of talkers: safe-sex talkers, general AIDS talkers, nontalkers, and want-to-be talkers. Safe-sex talkers had talked to their sexual partners about AIDS prevention, condom use, and sexual history. General AIDS talkers had discussed AIDS-related topics with their partners, but not in the context of the personal relationship. Nontalkers had never discussed AIDS with their partners and never wanted to. Want-to-be talkers had never discussed AIDS with their partners, but wanted to do so.

Subsequent analysis identified characteristics that differentiate the four groups (Cline, Freeman, & Johnson, 1990). The four groups did not differ in demographic characteristics, level of knowledge about AIDS, or perceived risk of acquiring AIDS; nevertheless, women discussed AIDS with their partners more often than men did. The authors suggest that respondents may have considered discussing AIDS a threat to the relationship. Respondents were more willing to risk their health rather than discuss AIDS and risk ending their relationships. Lear's (1995) analysis of in-depth interviews with 30 undergraduate men and women generated similar findings. Lear concluded that in an established relationship, negotiating safer sex could be perceived as a lack of trust. In fact, discussing safer sex with a partner might be perceived as being more intimate than sexual intercourse itself. On the other hand, some individuals may perceive that a potential partner's willingness to discuss AIDS is evidence of honesty and openness, suggesting that the potential sexual partner is less risky (Cline et al., 1990).

Despite their concern and increased risk of contracting STDs and HIV, research has shown that adolescents perceive themselves as being at low risk for acquiring AIDS because of their current monogamy, lack of intravenous (IV) drug use, and trust in their partners' safety (Overby & Kegeles, 1994). In addition, few discuss AIDS-related risk …