Condom use negotiation in heterosexual African American adults: responses to types of social power-based strategies.

Research has shown that couples who can communicate openly about condom use and safer sex are more likely to reduce HIV behavioral risk through safer sex methods than couples who do not discuss these issues (e.g., Catania et al., 1992). Thus, effective HIV risk reduction behavior change interventions routinely teach participants sexual assertiveness, communication, and negotiation skills. The goal of sexual negotiation training in the context of HIV prevention is to help individuals develop communication skills needed to persuade sexual partners to avoid risky behavior. These skills are taught using a number of methods, which include modeling, role playing, and behavioral rehearsal of sexual communication strategies; encouragement to communicate condom use requests with partners; and reinforcement of negotiation efforts. Skills-training-based interventions using methods such as these have been effective in decreasing HIV risk in a number of populations, including gay men (Kelly, Lawrence, Hood, & Brasfield, 1989; Valdiserri et al., 1989), at-risk inner-city women (Anderson et al., 2006; DiClemente & Wingood, 1995; Hobfoll, Jackson, Lavin, Britton, & Shepherd, 1994; Kelly et al., 1994), adolescents (Jemmott, Jemmott, & Fong, 1992; Rotheram-Borus, Koopman, & Haignere, 1991, Rotheram-Borus et al., 2003; St. Lawrence et al., 1995), adults with serious mental illness (Carey et al., 2004; Kalichman, Sikkema, Kelly, & Bulto, 1995; Otto-Salaj, Kelly, Stevenson, Hoffmann, & Kalichman, 2000; Susser et al., 1998), and persons living with HIV infection (see meta-analysis by Johnson, Carey, Chaudoir, & Reid, 2006). Implicit in this skills training is the assumption that the negotiation strategies taught to participants are perceived positively by sexual partners, and are effective in persuading sex partners to use condoms. Despite the prominence of facilitating the development of sexual negotiation skills in HIV risk reduction interventions, however, little is known about people's perceptions of and reactions to various negotiation styles. The process of initiating discussion around sexual negotiation has not been closely investigated. We do not actually know how difficult initiation may be for people, and we have little understanding of people's beliefs regarding what they might gain or lose as a result of successful or unsuccessful negotiation efforts. Currently there are no data that show whether negotiation activities used by men or women maximize the likelihood of safer outcomes while minimizing the likelihood of negative social outcomes.

Although current HIV risk reduction interventions assume that strategies taught are effective in causing behavior change resulting in condom use, there are many dimensions of response other than behavioral compliance such as affect toward the negotiating sex partner, or even behavioral noncompliance resulting in actions that destabilize the relationship, or even violent actions. It is probable that some methods of negotiating condom use may be more apt than others to elicit positive affect and compliance from targets of negotiation. Several studies have described reluctance among women participants to negotiate condom use with partners for fear of precipitating angry or violent reactions from their sexual partners (Sobo, 1993; Wingood, Hunter-Gamble, & DiClemente, 1993), especially those with known histories of violence (Beadnell, Baker, Morrison, & Knox, 2000; Wingood & DiClemente, 1997).

Perhaps certain negotiation styles may have unintended or negative relationship consequences such as unpredictable, angry, or even violent reactions in partners who are not open to such requests. Thus, understanding individual perceptions and reactions to negotiation attempts is necessary to develop effective skills-based interventions. Indeed, much of the research on communication in sexual negotiation has evaluated the selection of strategies and decisions made by the negotiator (e.g., Feeney, Kelly, Gallois, Peterson, & Terry, 1999; Lear, 1996; Monahan, Miller, & Rothspan, 1997), and has not taken into account the perception of the message by the person for whom the persuasive message is targeted.

It is also likely that the perception of the target of negotiation also is affected by other factors, such as the relationship between the members of the dyad, their previous history, and the gender of the negotiator. For example, several studies with college students have found gender differences in perception of negotiation strategies. DeBro, Campbell, & Peplau (1994) presented written vignettes portraying different condom use negotiation strategies to male and female college undergraduate students. Female students rated negotiation strategies depicting the provision of risk reduction information, condom use reward (emphasis on use of condoms enhancing the relationship), and withholding of sex as more effective and comfortable strategies than did male students. By contrast, male students were more likely to rate the use of seduction--use of sexual arousal to distract partner in order to gain compliance--as the most effective and comfortable strategy to influence a female partner to use a condom.

The results of another study demonstrate gender differences and the potential for inconsistencies in attitudes and behavior when negotiating condom use. Edgar et al. (1992) created written scenarios depicting nine possible styles of interaction between sexual partners negotiating condom use. College student participants identified the types of communication strategies they would use and those they believed would be most persuasive when used with a condom-resistant sexual partner. Although the correlation between the mean scores for likelihood of use and perceived persuasiveness was high for all strategies, gender differences existed: although male students reported high intentions to use communication styles they found persuasive, ratings of probable use and perceived effectiveness often were dissonant from one another for female subjects. These inconsistencies were especially striking for two strategies: a direct approach (characterized as "Yes, I want [you] to use [a condom]."), and a power-reward approach (characterized as "If [we] use one, I promise you I'm going to make you feel so good that [losing an erection] isn't going to happen."). Women rated the direct approach high on probable use, but did not perceive the strategy to be very effective. Conversely, women rated probable use of power-reward as low, but rated the perceived effectiveness of this strategy as high. Thus, gender differences may not only exist in strategy use and overall evaluation, but they also may reflect differential--and perhaps dissociated--assessment of cognitive and affective components discussed earlier.

In addition, while research has demonstrated individual and gender differences in perceptions of condom use negotiation strategies, the use of college undergraduate student samples may limit the utility of the findings for program development with populations most at risk. College students typically differ from inner-city young adults culturally, in communication style, gender role socialization, and risk issues (Amaro, 1995; Cochran & Mays, 1989; Worth, 1990). In addition, previous research has not attempted to establish a theoretical base for strategy assessment. An appropriate theoretical framework is necessary to guide subsequent research in this area.

Thus, this study chooses to examine perception of condom use negotiation in the context of a social power framework. Models of social influence attempt to explain the conditions under which people negotiate with others, and the extent to which those negotiations tend to be successful or not. These models suggest that (a) behavioral compliance may not always reflect underlying attitudes, and (b) context is often key to successful negotiation.

Although conceptual frameworks for social influence have been studied extensively in business and everyday interpersonal relationship contexts, they rarely have been applied to the issue of sexual negotiation in HIV prevention. One such framework designed to take in the complexity of negotiation acts is provided by the Power/Interaction Model of Interpersonal Influence, Raven, 1992). This approach suggests the existence of power "bases" from which influence strategies are produced, and posits that people may choose methods that, in part, reflect their own sources of power (see meta-analysis by Carson et al., 1993). Many social influence researchers (Bisanz & Rule, 1989; Falbo & Peplau, 1980; Johnson, 1976; Lips & Colwill, 1978) suggest men's and women's styles of influence are characterized by the use of different strategies, and they propose this is because of gender differences in bases of power from which people choose negotiation tactics.

Raven proposes six bases of power from which people derive strategies attempting to influence the behavior of others: (a) reward; (b) coercion; (c) legitimate; (d) expert; (e) referent; and (f) information. According to Raven, coercive and reward power can refer to real physical threats and tangible rewards, but they also can include personal rejection or approval. Legitimate power is derived from the structural relationship between the influencing agent and the target; the agent may implicitly or explicitly communicate that she or he has a "right" to ask the target to engage in some behavior, and that the target has an obligation to comply. Expert power is acting on the assumption that the powerholder is "correct," while referent power refers to engaging in a behavior because of a sense of connection or relationship with the influencing agent. Finally, informational power is based on the logical argument that the influencing agent can present, either directly or indirectly, to the target in order to implement change.

For several reasons, it may be appropriate to investigate perception of condom negotiation strategies using this model. First, the described bases of power, when translated into forms of sexual negotiation, seem to reflect strategies discussed in HIV risk reduction interventions having a negotiation component (e.g., Otto-Salaj, Kelly, & Stevenson, 1998; Sikkema et al., 2000). Also, power differentials are socially derived and therefore inherent in relationships (e.g., Kipnis, Gergen, & Castell cited in Kipnis, 1976; Johnson, 1976; Raven, Centers, & Rodrigues, 1975) and are cited as factors in the use or nonuse of condoms among sexual partners (Mays & Cochran, 1988).

Although sexual risk reduction is of equal importance to men and women, available educational programs typically assume that women and not men should be the recipients of negotiation skills training. Evidence suggests that whether or not condoms are used is strongly influenced by sexual communication between partners in a male/female relationship (Catania et al., 1992) and patterns of traditional sex role socialization (Mays & Cochran, 1988). Gender role stereotypes and gender scripts traditionally have discouraged women's initiation of sexual discussion, and recent research suggests that adherence to more traditional sex roles may inhibit women from successfully negotiating with their sexual partners (Beadnell et al., 2000; Bowleg, Belgraver & Reisen, 2000; Wingood, Hunter-Gamble, & DiClemente, 1993). In addition, Quina et al. (2000) found that communication within a sexual relationship is influenced by the power dynamics of the relationship; for women with sexually abusive partners, this resulted in less communication. Quina and her colleagues concluded that hesitation to express sexual needs and to discuss HIV risk reduction are based on the perception of power and interpersonal danger in the relationship. Because the male condom is the most commonly used form of HIV prevention, HIV prevention is perceived by men to be under their control. This coupled with lack of power in negotiation of safer sex are cited by women as reasons why they do not practice safer sex (e.g., Wingood & DiClemente, 1997). At least one study (Fleisher, Senie, Minkoff, & Jaccard, 1994) found that willingness of a male partner to use condoms predicted condom use among Latina and African American women.

Using a social power framework also may help us determine the ways in which the act of negotiation affects the perception of the partner. Empirical research suggests that the use of persuasive messages also may affect the target's emotional response and perception of the person delivering the message (e.g., Kipnis, 1976; Kipnis, Schmidt, Price, & Stitt, 1981; Mitchell & Wood, 1980; Wegener & Petty, 1996), and that this is not just the result of the message content, but also the interaction of the message with other aspects of the situation, such as affect for a significant other (Kipnis, 1976). In the case of condom use negotiation--a potentially emotionally charged subject--the target's perception of his or her partner may differ from his or her perception of the content and "spin" of the message. For example, while a target of a persuasive attempt may think of his or her partner very positively, and even may feel generally neutral about using a condom during sex, he or she also may view the specific strategy used to negotiate condom use very negatively. Research has suggested that negotiation attempts can affect both the target's evaluation of the negotiator, and the negotiator's evaluation of the target (e.g., Kipnis, 1984); these evaluations can have a strong affective component. In other words, the act of negotiation may affect how the people in this partnership feel about one another in significant ways.

Understanding how people perceive condom use negotiation strategies would make it possible to use an evidence-based approach to guide the design and construction of negotiation skills training used in HIV risk reduction interventions. In turn, this would allow those who conduct HIV prevention interventions--and those who participate in them--to have greater confidence that the negotiation skills and styles taught will be high in social validity and therefore more likely will lead to positive outcomes for the partners. Consequently, examining sexual negotiation from a social influence or social power theoretical perspective may help to elaborate the dynamics of sexual negotiation.

This study examined gender differences and preferences in the use of and response to six different styles of condom use negotiation with a hypothetical sexual partner of the opposite gender. Participants in this study were heterosexually active African American men and women attending an inner-city community center. In 2002 (the most recent year for which data are available), HIV infection was the leading cause of death for African American women aged 25-34 years, and the third leading cause of death for African American women aged 35-44 years (Centers for Disease Control and Prevention [CDC], 2005). For these reasons, African American men and women often are targeted for inclusion in HIV risk reduction interventions, including those focusing on negotiation skills training (e.g., DiClemente & Wingood, 1995; Kelly et al., 1994; Jemmott, Jemmott, & Fong, 1992; St. Lawrence et al., 1995). In particular, many interventions appear to target African American women (DiClemente & Wingood, 1995; Kelly et al., 1994; Sikkema et al., 2000). Traditional gender role adherence may be particularly salient in this population (e.g., Ehrhardt, Yingling, Zawadzki, & Martinez-Ramirez, 1992; Wyatt & Riederle, 1994). Therefore, understanding negotiation strategies among this atrisk population is greatly needed.

The intent of this research is to improve our understanding of the social consequences of condom use negotiation and, by doing so, accrue information that can guide the selection of the types of negotiation skills taught in HIV risk reduction interventions for men and women.

Method

Setting and Participants

A convenience sample of 51 heterosexually active men and women (28 men, 23 women) was included in the present set of analyses. All participants were of African American ethnicity, were heterosexually active in the 3 months prior to interview, were between the ages of 18 and 35 (median age 29.7), were unmarried, and gave written informed consent for project participation. All participants were recruited from an inner-city community-based service center providing outreach, social service, and recreational programs for African American men and women. The educational level of 22% of the sample was college or higher (range, 8-16 years). Forty-eight percent of the participants were unemployed. Fifty-three percent of the sample (36% of men, 57% of women) were involved in some type of a steady relationship. Twenty-eight percent of the sample (39% of men, 13% of women) did not have any children.

Procedures and Measures

In the community center, recruitment for the study was performed using face-to-face meetings, brochures, and posters. Interested persons were screened briefly to determine whether or not they met criteria for study entry. Informed consent then was obtained from persons who met screening criteria, and participants then were interviewed in a private center room. Semistructured interviews were conducted by Caucasian and African American researchers trained specifically in the administration of this qualitative interview. All interviewers had previous training and experience in facilitating sexuality education and HIV prevention, and they took notes during each interview. Interviewers were gender matched with study participants to assist participants with comfort in disclosure of potentially sensitive information. Quality assurance was conducted by an anthropologist skilled in qualitative interviewing techniques, who listened to interview audiotapes, read notes, and met with individual interviewers to discuss interview activity, obvious conversational bias, and other field issues typical in qualitative inquiry. Emphasis was placed on adherence to the interview protocol. Audiotapes also were compared with transcripts to ensure quality of transcribed text.

Although interviewers remained flexible so that unanticipated information could be collected when it arose (Spradley, 1980; cf. Dorfman, Derish, & Cohen, 1992), the interviews were semistructured. Each interview included a schedule of forced-choice and open-ended questions. For this study, several hypothetical scenarios--in the form of negotiation strategies used in sexual situations--also were used to elicit information.

Data presented in this study are part of a longer qualitative interview of participants' experiences with condom use negotiation. In this segment of the interview, we instructed participants to think of the negotiator as a "steady" sexual partner. Research shows that couples in longer-term sexual relationships are less likely to use condoms than couples in newer relationships (Dolcini et al., 1993; Erikson et al., 1995; Hays, Kegeles, & Coates, 1997; Laumann, Gagnon, Michael, & Michaels, 1994). Thus, we chose to attempt to identify strategies that would be most effective in situations where unprotected sexual behavior is established and habitual.

In the context of the interview, participants were given the following instructions: "You will be given an example of something a steady sexual partner might say to you. After I present each statement to you, I will ask you a few questions about your response to it. Do you have any questions before we begin?" Participants then were presented with each of the following statements, used to represent each of the six types of negotiation strategies founded on the power bases described in the Power/Interaction Model of Interpersonal Influence (Raven, 1992):

Coercion: If a steady sexual partner said to you that if a condom wasn't used, s/he wasn't sure that s/he wanted to have sex with you or continue the relationship:

Reward: If a steady sexual partner said to you that s/he thought condoms made it easier to "let go," that s/he thought you both could have sex for a longer time when using one, and that s/he knew some things that would make you feel really good while a condom was being used:

Legitimate: If a steady sexual partner brought up condom use as the "responsible thing to do":

Referent: If a steady sexual partner brought up condom use by saying that s/he respects you a lot, that condom use would be the best thing for you both, and how great you would be if you went along with it:

Expert: If a steady sexual partner said that s/he's learned a lot about using condoms, and that the more s/he learns about them, the more s/he wants to use them, so it's a good idea that you use one:

Informational: If a steady sexual partner brought up using condoms by saying that s/he saw a TV show that talked about HIV, and how effective condoms are in keeping people safe from HIV, and so what do you think about using a condom:

Following presentation of each negotiation strategy, participants were asked, "How would you react?," "How would you feel?," "How would you feel about him/her?," and "Do you think you would agree to condom use? [Explain]." Statements were presented in the same order for all participants. Narratives of participant responses were collected on audiotape, and notes were taken by interviewers. Following interview completion, all interview audiotapes were transcribed. No individual identifiers were collected to ensure the anonymity of the participants. After transcription, the audiotapes were destroyed to further protect participants' anonymity. Interviews generally lasted from 45 minutes to 1 hour; the segment of the interviews reported here generally lasted 10-15 minutes.

Data Analysis

A senior researcher experienced in qualitative research reviewed the interview audiotapes and prepared a separate summary report of the responses elicited in the men's and women's interviews. All transcripts and notes were utilized in the analysis. Initial reading of notes and transcripts focused on identifying key themes and meanings suggested by words and phrases that occurred in response to each question. For this study, topics regarding participant response to each of the negotiation strategies follow: What overall behavioral response (condom use/nonuse) does each strategy invoke; what participant affect is induced by each strategy; and what affect is experienced by the participant toward the model for each strategy. Then the authors examined themes across the transcripts and developed broader conceptual domains. Quotes then were extracted that illustrated common responses and themes across groups.

Results

We investigated responses to negotiation strategies on various dimensions, and we found definite gender differences in perception and response. Initial analyses were performed on female and male participants separately.

Women

Referent power strategies. Among women participants, the most positive responses were given to the strategy representing referent power. When women were told that their steady sexual partner brought up condom use by saying that he "respects you a lot, that condom use would be the best thing for you both, and how great you would be if you went along with it," many participants indicated positive affect toward the attempt and the negotiator, and indicated willingness to acquiesce to the request:

(Referent): My heart would start to flutter and I'd say okay (laughter). [019]

(Referent): I would tell him, "You don't gotta keep runnin' them lies (laughter)," and how I agree with him with the protection, but he don't gotta keep tryin' to sweet talk me, [all] of that with it. [010]

(Referent): Even better [than legitimate], cuz he said it's best for us, and we are seein' that we will be on the same level, he won't be a level beyond me. [014]

(Referent): Great, glad he feel as though we both should be on positive, positive atmosphere. [047]

Reward power strategies. Women participants were next most likely to respond positively in both affect and behavioral response to use of strategies of reward ("I can make you feel really good") power. Several responses were short and "to the point," such as "(Laughter) let's try the freak (laughter)!" [002], "Come on with it (laughter)!" [030], and "I'd be like, yeah. C'mon! Yeah, let's try it." [046]. Although women's comments regarding negotiation strategies tended to be less detailed than those given by men, the most detailed responses among women tended to be elicited by the reward strategy; many viewed this type of approach as novel:

(Reward): I ... be excited because he ready to try new and interesting things. Cuz a man, to get bored with one woman for a while, you know, that's what make him go mess around. See, I'm into doin' some thin' different ... so I'd probably be able, I would be able to go with that, you know what I'm sayin'. We just have an adventure together. [050]

(Reward): I would think I would like that more, because, well, like not usin' a condom he actually, he nuts really quick, so I would like the idea of him going longer, and I would like the idea of him doing something that would make me feel good, you know, because sometimes it's just a fuck. I'm a realist, you know ... and and sometimes I guess I want to be have made love to, besides a fuck, so I think I would like that. [028]

Responses to reward strategies, however, were variable: Many women also expressed concern and dislike for this approach. These responses appear to be tempered by disbelief in several ways. Some participants expressed distrust in the motivations of the partner, reflected in the wording of the request:

(Reward): Hmmmm, my mind get to wondering, I don't know, what is he up to? What he talking' about, he tryin' to play a game or somethin'? That's what I'd think. I don't think I'd like him too much, cuz he I don't think he take it serious. I don't think I like that, I think it's turn me off cuz how he said it would turn me off, the way he came to me. [013]

Other responses reflected participants' disbelief that the sexual activity to follow would actually be of higher quality or longer duration:

(Reward): If he would say that he would try it, ... he better not be lyin' because if it [erection] goes down and don't last as long as it usually do, then we would probably never use it again. That was a good one. [019]

Legitimate power strategies. Responses to legitimate power strategies--condom use as the responsible thing to do--also were variable. Several participants expressed positive affect for the partner and a willingness to use condoms in response to such a request:

(Legitimate): You gotta build trust in a relationship and I would be like this, you know, that he got his head on right. He thinkin' about the future, he thinkin' about hisself, you know, and then he thinkin' about me too cuz ain't no telling what he got, so I'd be good for that you know. [002]

(Legitimate): [I'm] fine with that. We're thinking on the same wavelength. I'd feel like he was thinkin' like me, he cares about this relationship. [048]

With some participants, use of this strategy elicited concern that the negotiator believes the participant has not been responsible in sexual conduct, or additional questions about why condom use was requested:

(Legitimate): If I just say, he brought up to me bein' responsible, I'd be like, "What, you think I got somethin?'" [046]

(Legitimate): First, I actually want to feel like it's responsible to. Why we have to go that route?... Give me a good enough reason to, why would we, why would we have to go that route? [047]

Expert power strategies. Women participants responded somewhat neutrally to expert power strategies ("I've learned a lot about using condoms...), with statements implying general agreement and acquiescence:

(Expert): Oh, teach me. If he's a good teacher, I'll feel a lot better. [048]

For some participants, however, the strategy appears to imply that the negotiator has multiple partners:

(Expert): How would he know if he hadn't tried it [with someone else]?.... If he just bring it to me now, how would he know what, what it, all the experimentin' and the good things it do for him if we never did it before? So I would wonder a little bit, but yeah, I would probably be a bit curious, too (chuckle). [050]

Informational power strategies. Negative responses by women tended to occur most often in response to attempts to negotiate using informational power strategies ("Condoms are effective at keeping people safe from HIV"); however, affect did not necessarily correspond with action. Several participants expressed negative or ambivalent affect in response to the request, but also they said they would acquiesce to the request:

(Information): I would probably have a shock reaction.... I probably would, you know, be a little shocked at what the words he used, or, you know, the reason why he used it, that he wanna use it, but I would agree with him. [010]

(Information): I would use one, [but] it wouldn't feel, I don't feel--I won't have much respect for him because he seen it on TV. But I would have respect, because he's just as probably as scared as anyone [about getting] HIV or any other sexual transmitted disease. [014]

Coercive power strategies. Women responded variably to the use of coercive strategies. Some women responded positively in both behavior and affect, sometimes related to the perception that the partner is seeing someone else, and so is being caring and protective of the participant:

(Coercion): In a way, I be glad he'd say that, then I figure he be lookin' out for hisself and for me, so I kinda feel good if he would say that.... I would probably like him more so if he would say that, you know. Cuz then if he wouldn't say it to me if we're not together, say it so somebody else, you know. So I'd feel good. I'd feel better if he would say it. [I: Do you think you would agree to use condoms if he came to you that way?] Uh huh, I would.... Seeing how I wasn't doin' anything, he could trust me. If that's what he wanna do, he probably be protecting me from something. [045]

(Coercion): If you can get a man that can give you an ultimatum like that, then I think you found ya a good one.... It would kinda push me towards him. [047]

Although nearly all women said they would use the condom, a few women responded with more negative affect regarding the negotiation attempt using this approach:

(Coercion): I would just have to use it then. [I: How would that make you feel about him if he said that to you?] I would, I would [hate] him. [033]

Tone and approach in strategy use. Overall, women expressed a high valuation for men who broach the issue of condom use, and they demonstrated a greater willingness to use condoms than men in our sample. This is represented by remarks from one participant:

(Coercion): I would feel good about him, pat him on the back, because I think that's good that a guy asks a female to use a condom. I'd say nine out of ten, they won't ask no female to use a condom, they won't even bring up the subject. [014]

(General negotiation): I wouldn't mind, you know, if I found someone who wanted to use a condom all the time. I wouldn't, that wouldn't bother me at all. I would actually prefer that ... because it would relieve some of the burden off of you, yeah ... I wouldn't have ta worry about, you know. [051]

Tone and approach also were important for overall response by women participants, however, as represented by reaction to different negotiation strategies:

(Reward): Actually, if you get a man that's comin' to you like that, then you actually found somebody that's got a good sense in they head. Cuz nowadays, they don't.... You got those men out there that's just stickin' and movin' ... and don't care how they stick or move. So if you got a man that can actually put it down in face things to you like that, I think you should go for it. Cuz it's not only that he care for hisself, then he actually gonna care about you too. Cuz if he don't care about hisself, then how much do he think he gonna care about you? [047]

(Expert): I guess I would feel proud of him that he learned, you know, that, if he actually went somewhere and talked to someone and they told him.... He decided that, he did, you know, wanna do it. There wouldn't be angry feelings.... I guess it would depend on how he brings it to me also, though. [051]

Men

Reward power strategies. For male participants, reward strategies ("I can make you feel really good") drew the most consistent responses. In reaction to the strategy based on reward, most participants said they would use condoms, and would feel positive about their partner for having broached the subject in that manner:

(Reward): I would react by, "Let's get it, let's get it on!" [022]

(Reward): Where she at (laughter)? I wanna meet her! [I: How would you feel?] Shocked and happy and anxious, all of it. [Do you think you'd agree to use a condom then?] Oh yes, real fast (prolonged laughter). [018]

(Reward): I met the girl of my dreams (laughs)! I feel marvelous. If I met a girl like that, about her I would feel absolutely marvelous. [015]

(Reward): I would feel like that woman really knows what she's doin' (laughter)! [008]

(Reward): Well, I'm pretty sure you're right, but let's--let's see a few of those things that would, I would enjoy (laughter) more. Let's try this. I'd feel better than before, cuz it's just new experiences that's, that being brought on,... so, yeah, I'd have to say yeah, she's my kind of girl. [009]

(Reward): I'll try it, cuz a whole 'nother feeling started goin' though my mind, like, okay. She wanna go down on 'em, you know, on my penis, so I'll--I'm gonna try this.... "[I: How would you feel?] Excited, curious, anxious, heh, heh, you know. I wanna find out what these things are that are gonna make me feel good about usin' this...." [I: How would you feel about her?] I would think she was a freak, I'd feel as though ... she's done it before, you know, she did the experience, so, and it was something she liked and the--that man liked so she wanted to try it on me, so, like I said, I'd still be anxious. I'm still waitin' to find out what she talkin' about. [025]

(Reward): I would wanna see, I would want you to show me, um, never experienced that before, so I would have to go there, you would have to show me what you're talking about.... (I would feel) anxious (chuckle), very anxious, cuz like I say, I've never experienced it and um somethin' new like that, yeah, I would feel very anxious to know what you could do. [040]

Some participants expressed thoughts, however, that skills needed to eroticize condom use--following through on the "promise" of higher quality sexual contact--were paramount to their continued use of condoms after an initial trial:

(Reward): I probably wouldn't mind doin' it if she could show me somethin' that I don't know. [026]

(Reward): Sure I would try it, yeah, oh yeah. Yeah, cuz the more involved and intense they are, it's ... (the) more involved, the better it's gonna be for you. That's why they say they like touching and taking the time, cuz it gets them more aroused. As long as they're up, you're all good. So long as it's like the way she said it is, it's gonna be better and all that, and she knows some tricks, it's all good (laughter). It's all good. [024]

(Reward): I'd be like, okay. I wanna know, I would wanna know, my main concern--what can she do differently with a condom on? I wouldn't be offended.... I would think she was a freak (laughter). If she can do something to me that I don't know anything about, with a condom, that she can't do without.... I know, it would be questionable like, what--whatchu been doin', who you been talkin' to? [I: Do you think you would use a condom?] (Yes), just for the--the experience of what she can do with a condom. [005]

Skepticism that condom use could be pleasurable was expressed by some participants in this context:

(Reward): Since I ain't never had no experience in that, that I have to be like contessing (contesting) against that. Because the best feeling for me have been without the condom.... cause really, you know, I always felt like this a good sex when a woman have a good body.... It would do good with that release behind that good body.... That's magnificent. But with the condom on, then, naw. Cuz to me--I have done it--it seem like me just rubbin' 'gainst friction. I be curious, cuz my mind be curious about how do she feel on the inside--how does the inside feel? And I try to admit that I have done this--to go faster and harder to the point where I bust that rubber to see how she feel on the inside. [016]

For men, all other types of strategies drew approximately equal amounts of positive and neutral responses, with the exception of coercive strategies. For strategies based on legitimate, referent, expert, and informational power, responses ranged from moderately positive to moderately negative for affect toward the negotiator. Indications of condom use ranged from participants willing to use them with no issues or concerns, to participants being unwilling to use them. Few extreme responses were given by male participants in response to these strategies. In response to referent power ("I really respect you...."), a number of male participants expressed moderately positive affect and a willingness to use condoms. Several also expressed a feeling, however, that they were being "handled" by the negotiator:

(Referent): If she put it that way, ... that's gonna show me that even though I ain't used to usin' 'em, if she put it like that, that's, you know, she ain't just out to get some sex and be gone, you know. She tryin' to establish a relationship, so ... I'd roll with it. [025]

(Referent): If I'm not near her, I would--I would jump over anything to get to her,... because she said, you know, she respects me and she likes me, you know--just because it came out, not just because I believe it. [009]

(Referent): I'd agree. I'd agree. She's just tryin' to sugar-coat it (laughter), no shit. I'd tell her don't sugarcoat it though, but we'll use it. Cuz, cuz evidently she want it, the way she sugarcoat it, cuz she really thinks it's important and I think it's important. Important to have, have some type of birth control or some type of protection, and, um, yeah. If she, if she would like to use a condom, I, I'd use it. [012]

Other participants suggested they would try to "haggle" with the negotiator in response to this approach:

(Referent): She'd have to give me some reasons, pregnancy or what, you don't trust me.... Then we would have to compensate ... three nights out of the week without it, or four to eight nights out of the week with it, five nights out of the week with it and two without. We'd have to compensate. It's not just a one-sided relationship, you know. I respect your wishes and you have to do the same to me. It's not just you, you, you, you. You know, put in 60% or 40%. It's not even a 50/50 thing because if you do, you're gonna get two of the worlds clash and it's not gonna go nowhere, you know. You got 60/40 to compensate so things can, you know, you know, move freely. So I, so I could put in 60 and settle for 40. Six nights out of the week with rubbers, one night out of the week without it. Fair is fair. [021]

Responses to use of legitimate power ranged from "grudging respect" to questioning of request and potential nonuse. Some participants expressed modest agreement with the negotiator:

(Legitimate): Respectably, 'cause when people tell you something like that responsibly and being sincere, you can't argue with a sincere person on a top, on a very important matter like that, and I, you know, I hafta use one. [0161

(Legitimate): I would, I respect that, I respect that. I would do that out of respect cuz, you know, it was right, you know. I respect that, I would give that respect if she say it like that. [020]

Other participants expressed concern that the act of saying condom use is "responsible" implies that one partner or the other has NOT been "responsible," hence the occurrence of condom use request. In this context, responses often reflected dissatisfaction with the situation, and attempts to avoid condom use altogether or to at least to negotiate the conditions under which condoms are used:

(Legitimate): If we used condoms to get to know each other and ... you know, to prevent things, and then we get into the relationship a little deeper and find out that it's only us and we stop usin' them, and then we go back to it again cuz she says it's responsible--I would wanna know what kind of angle she's comin at, and I would listen to her and decide from there. [005]

(Legitimate): I don't think we would be in a relationship that long (laughter).... But I would probably if I liked that person. I'd probably try to deal with it--um, cope with it the best that I can. We'd work out some kind of agreement, where two nights we do it without it, two a couple nights with, do it with. [021]

(Legitimate): I'd feel as though she tryin' to tell me, you know, I'm stupid, I'm irresponsible or something, you know, so.... I'd feel insulted again like she's callin' me stupid or somethin,' so I'd be mad at her. Cuz like I said, I would feel as though she was callin' me stupid, I'd be like, "She thinks she's better than me or somethin,' she thinks she knows more than I do", so I'd be kind of upset with her. [I: Do you think you'd agree to condom use?] No, no, and then I'd tell her, I'd get the impression in my mind that she, she gonna get the impression in her mind--"Yeah, I got him, he gonna do whatever I want him to do now, he'll do this. Then, the next thing I'm gonna ask him, he gonna do it and then so far down the line," so I'm gonna figure she thinks she got me hooked--she got me to where I'll do whatever she want me to do. [025]

In response to the strategies based on expert power ("I've learned a lot about condoms...") and informational power ("Condoms can keep us safe from HIV..."), several participants expressed concern that the negotiating partner should explain how she learned about condoms, the content of what she learned, or from what source she got her information; the act of "knowing" or self-description of having expertise was not enough to convince these participants in and of itself:

(Expert): If she learned something, she should be able to share the information with me. [011]

(Expert): I would react like I wanted to find out what she learned and where she learned it (laughs). [015]

(Informational): I think I'd ask her what, you know--what the TV show was, cuz like--if she tell me some soap opera, I'd tell her get out my face, like, you know, soap operas--they ain't anything, but, excuse my language, they ain't nothing but fuckfests anyway. Everybody sleep with everybody. But if it was like, what can I--I'm tryin' to think of one of the educational shows, um, if she saw it on somethin' like the Cosby--remember the Cosby Show when it was on? If she seen it on somethin' like that, you know, I'd probably be more open to it... So it all depends on the show she tell me she got it off of. [I: "How would you feel?] I ain't mad, but I ain't happy. [025]

The issue of trust was also of concern for some when these strategies were presented; for some, this was serious enough to elicit concern that either the partner was unfaithful or suspected the participant of being unfaithful:

(Expert): Bein' the nosey person that I am, I'd wanna know how she found out so much about, I'd feel really nosy and get to askin' her a bunch of questions. I don't know why, but, there's somethin' about me.... It ain't nothin' I can do nothin' about, but I don't too much like havin' sex with women that done had a whole bunch of partners.... I would wanna know how she knows so much, so, um, I guess the best word is jealous, you know ... (and) I'd think she a freak, you know, a woman willing to do anything. [I: Do you think you'd agree to condom use?] No. Well, then again, it all depends on how she told me she learned about it. If it's some half-way decent answer, then, yeah, I'd agree to it. [I: "What would a halfway decent answer be for you?] Like she read up on it or somethin', like she read the bottom of a book or somethin'. But if she told me she learned from experience, I think I'd have to go. [025]

(Expert): I would tell her she crazy and lost her mind, and why all of the sudden ... and then like I say I would probably use it, you know, a couple of time, yeah. Why not. Like I say, ... I may do it just to, you know, satisfy her for the minute, if I wanted to, you know, and then be like, "Okay, that's enough of that." [I: "How would you feel?] I don't know.... I would probably feel a little like messed up, like, what's all the sudden out the blue, like, you know what I'm sayin', you know, what's goin on?... I'd probably be a little hurt, a little shook up. [024]

(Information): Contest it, uh huh. I think it would be like a big argument about it now, 'cause I feel like, "why you don't wait till you seen something on TV and start getting these thoughts," you know. That what I ask her. And that'll piss me off, you know, cuz it make me think yon runnin' game, meanin' that you tryin to run ... tryin' ta be conniving about the situation. [016]

(Information): It ain't no reason. I'm not messin' outside and you ain't either, so I don't agree with that. I, ah, piss on that. If I know she home with me everyday, so why use condoms for if we ain't doin' nothin'.... HIV it's just a big letter word. It's there, but what would I use for what, and I ain't doin', and she ain't tryin' to do nothing, so hey. [020]

A few participants expressed concern that use of the wording of the informational power strategy reflected a need for concern that the female partner is HIV positive, as evidence by the following quote:

(Information): I would sure be lookin' at her like she had HIV, if she wanted to have sex, really. Because if a person come to you and say, 'Well, I just saw a TV show sayin'--stating that you know about HIV and the condom help protects the other person from, from getting HIV," then you know that would linger around in your mind.... I know womens that have HIV and, uh, they have--they don't use the same kind of condoms that we use, they use those pretty thicker ones when they have sex, and that scares me and that would scare the hell out of me, you know, if someone come up here and say somethin' like that to me. [017]

Coercive strategies drew the most variable range of responses from male participants. Responses regarding acquiescence to the request ranged from agreeing to use a condom to a reluctant agreeing to use a condom, and affect for the negotiator (female partner) ranged from feeling minimally positive about that partner to expressing negative affect for that partner. In this way, responses to this strategy of negotiation provided the most troublesome data in the study. Not only did these data indicate heightened probability of negative consequences for the health of the relationship, but these data also call into question the use of this type of approach in any risk-reduction education intending to benefit heterosexual couples in this population. Trust--or lack of it--often was mentioned in this context:

(Coercion): I'd ask her to change her tone of voice or whatever, but I'd still use the rubber as she asked.... I'd probably go ahead and use it because it seem like the way she was asking that she didn't trust me, so to put back my trust against her, I'd probably go ahead and use it. [026]

(Coercion): I would feel let down,... cuz she don't trust [me]. [022]

(Coercion): I think it would tell, it would let a person know that maybe there's a little bit more work to be done in the trust area. And maybe, if there's, if there's--hypothetically--if a situation like that occurs, maybe one should, ah, recommend testing on both parts so that some of that could be, some of the fear in that relationship could be, ah, erased or put aside at least for until the test results come back. So that, you know, both of you--you'll know what you, where you stand, yeah. [023]

(Coercion): Very disappointed.... I'd probably go off talkin' about why (chuckle), you know, first of all, why... Then I'd probably start crawlin', we can use the condom, you know, why does it have to end the relationship?.... I would feel sort of like somebody stuck me in my heart with a sharp object, pain. Especially if I cared for that person, you know, and thought they cared for me. I would be kind of hurt.... I I would still probably like her or have love for her, but I would, I would be sittin' up tryin' to understand why are you tryin' to hurt me, you know. I've walked away from a whole lot of situations similar to that, but, um, that is just feelin' that in you heart, you know, it's like a straight pin goin' through your heart, just a pierce in your heart. [040]

(Coercion): Whad you, you messin' up? Am I mess--you think I'm messin' around? I mean, why all of a sudden.... How would I handle that? Um, I don't know.

I might, I might not have sex with her for a minute, you know. Not to say that we're not,... but why, to see, you know, if she stuck to her guns. [024]

A subset of men reacted very adversely to the coercive negotiation strategy. Several responses indicated that the participant would leave the relationship in response to a request worded in this fashion:

(Coercion): I'd agree to leave, heh, heh. I'll agree to leave, like I said. I'd be insulted, I'd be hurt, so I think I'd just leave, go find me somebody else. [025]

(Coercion): Well, I'd tell her ... I would tell her it be best for us to go our separate ways, you know--ain't no use in wasting time cuz this is a valuable subject, talkin'--talking about this on something that ... that we feel like we know we don't have no feelins for one another no more or whatever.... I still have feelins for her, you know, if it was in a steady relationship. But if it's just a bump 'n grind thing, somebody I met and found her just sexual attractive, ... I wouldn't care, you know. Poof, be gone. That type of thing. [016]

Responses from another subset of participants suggested the potential for violent action as a result of use of a strategy based on this approach:

(Coercion): I would probably flip, it would probably trip me out, you know, and I'd say something crazy, but if it's in that hot moment, you know, I'd use the condom then probably snahehp (snap) later, you know. [027]

(Coercion): Oh, I'd be pissed! I'd be pissed when she even say that ... I would feel that then if you feel that there's a condom being used, I feel that this relationship don't have any trust and that you been doin' somethin' wrong. [034]

(Coercion): I probably say, "This bitch--what's wrong with her?" [041]

(Coercion): How would I feel? I would feel kind of bad, feel a little sad, heh, and I would feel, ah, heh heh, very, very angry. [035]

Thus, while the use of coercive negotiation strategies may overtly result in condom use for the moment, the use of this type of strategy may result in destabilization of the relationship with that partner and the potential for violence within that relationship.

Value of relationship. For some men, the value of their relationship with the steady sexual partner appeared to mediate level of acceptance of negotiation attempts, and it may explain the variation in responses. If the relationship was valued by those male partners, then almost any type of negotiation strategy seemed to suffice in persuading that partner to use a condom during sex:

(General negotiation): To me, background means everything. I mean, just keepin' it real, you know. It depends on how she carried herself, ... but if she was a good woman or somethin' like that, then I feel like it's a 50-50, so I'm, ah, go ahead and I'm gonna agree to what she say, and if I don't like it, I'll just let her know, so. [038]

(General negotiation): If I feel like, well, I'm, I'm not losin' anything, then, so be it. But if I really care, or if I really want this certain person, then I would use the condom, you know, to keep that relationship goin'. [017]

(Legitimate): It depends on how you care about a person, see how deeply you're involved.... Somebody just, like I say yeah, we fuck biddies, but then, there's a different level, you know. I mean, you fuck buddies with (her), you know like I'm sayin', whatever, I'm, I don't care, I move around if we fuck buddies, but we--our relationship is someone I'm--I like enough and interested and say well, maybe later on, after I feel like I've sowed my oats or seen what's out there and she's the best thing goin', it may move into somethin' else, to another level. So it would depend on, at that point if that came up, how we, ah, how I actually felt ... searching myself and seein', you know, if I wanted to really go there with it. [024]

(Information): It depends on how long we been together. If I--if this was like a first time thing, it wouldn't be nothing, but if we'd been together for a while, then I'd feel like, you know, she didn't trust me or somethin'. [I: How would you feel about her?] Shaky. I'd think she was doin' something or she don't even trust me, she think I'm doin' something. [I: Do you think you would agree to use condoms?] We'd have to talk--what's goin' on? Why would she, why would she bring up somethin' like that? [032]

In the context of coercive strategy use, the few positive responses expressed also reflected high valuation of the relationship by the male participant:

(Coercion): It really wouldn't bother me. It wouldn't bother me. Like I said before, you got to respect her wishes. She respect mines, you know. The first way I met her is by listening to her, so you got to keep what you did in the beginning. [011]

(Coercion): I'd think okay, fine, we'll use one. She's comin' at me with a strong demand--I guess that's what she wants, so, I'm just gonna listen to it and this is what she wants. I'd still love her. It's two people in a relationship, so it can't be one-sided. You gotta give and take, things like that, so if that's what she wants, that's what she wants. [005]

(Coercion): You need to say, 'no more, sweetheart. I'm ... happy to hear you say that.... I would love to, we have to.... [I: How would you feel?] Very joyful, you know, that--that she's concerned about me, really, you know, cuz obviously she concerned about herself cuz she's presentin' that. So that's like, pretty--that's a woman, or respectable young lady. Put it that way. That's like a rose presented to ya and never been presented before, like one of those feelings, you know, very good feeling. [009]

Discussion

Contemporary theoretical formulations of HIV risk reduction and many trials of HIV prevention interventions reported in the literature emphasize the role of condom use negotiation strategies as a means to implement behavior change. Interventions to assist persons in reducing risk for HIV infection have drawn upon a number of behavioral science theories, such as the theory of reasoned action (Fishbein & Ajzen, 1975); social cognitive and self-efficacy theory (Bandura, 1989); the information-motivation-behavior model (Fisher & Fisher, 1992), and the AIDS risk reduction model (Catania, Kegeles, & Coates, 1990). Although these theories approach the issue of HIV risk behavior changes from different perspectives, they all posit that behavioral skills--including the ability to communicate condom use requests with sexual partners--are important determinants of success in risk reduction behavior change. Effective sexual communication between partners is associated with a variety of safer sex outcomes, including increased condom use (e.g., Catania, Coates, & Golden, 1994; Catania, Coates, & Ford & Norris, 1995; Waldron, Caughlin, & Jackson, 1995) and more effective contraceptive use (Inazu, 1987; Polit-O'Hara & Kahn, 1985). There has been little qualitative research, however, examining sexual discussion and negotiation to examine exactly how men and women describe their own or a typical sexual partner's response to different types of condom use negotiation requests. There is a pressing need for research to evaluate the impact of different negotiation strategies so that HIV prevention efforts can focus on those strategies that maximize the likelihood of positive outcomes and minimize the likelihood of negative outcomes.

This study found that the type of condom negotiation strategy used may be an important determinant of the outcome of the request. Indeed, certain strategies may be more likely than others to elicit positive outcomes such as sexual partner agreement and cooperation or elicit negative outcomes including noncooperation, anger, conflict, or even violence. Further, there were definite gender differences in response to types of negotiation strategies. Women participants in our sample responded best to referent, reward, and legitimate strategies, and worst to informational tactics; under these circumstances, HIV prevention efforts targeted at men would be best advised to concentrate on skills training in condom use negotiation strategies utilizing reference to respect for the woman partner and sexual pleasure associated with condom use, and to avoid strategies emphasizing the provision of information related to disease prevention.

On the other hand, men responded best to reward strategies, and worst to coercion strategies. Responses given by a subset of both women--and to a greater extent, men--indicated that use of negotiation tactics involving coercion to use condoms may result in negative and even angry or violent reactions. Especially among some men, the potential for violent response to a "no condom, no sex" strategy was clear. Further, negative affect did not always correspond with refusal to use condoms, but it may have other consequences such as increasing the likelihood of intrapersonal violence between sexual partners. Our research strongly suggests that while coercive messages might work to persuade some partners to use condoms during sex, they also may produce unintended consequences for partners in relationships where the negotiator must decide in the moment how to handle an unpredicted reaction.

These issues are equally pertinent for women and men, since male condoms are still the most common HIV prevention barrier protection method. Until men routinely are trained and accepting of responsibility for the consequences of their sexual activity in health matters, women often are singled out for training to be the negotiator of condom use in order to protect themselves and their partner.

For women who have relationships with men who respond negatively to coercive strategies, use of these negotiation approaches may actually encourage problems in their relationships. Under these circumstances, use of coercive strategies, as evidenced by our results, is not advised; rather, these results suggest that women will be more successful in negotiating condom use--and in avoiding negative affect from male sexual partners--if they emphasize the pleasure of sexual activity in the context of condom use.

Our results involving use of reward and coercive strategies by female sexual partners are especially interesting in light of other information from our interviews: When women were asked in another part of the interview what strategies they would use in real life with a sexual partner, strategies based on reward were generated by only one female participant. The other participants most often responded that they would try strategies based on information--condoms prevent HIV infection, and coercion--specifically, the withholding of sex if condoms were not to be used. Indeed, coercive strategies were, for many participants, the only strategy they independently generated. This finding may be an artifact of the American social constraints that hold women accountable for unwanted consequences. In addition, this probably reflects widespread influence of public service announcements and media campaigns, which have tended to emphasize prevention messages based on coercive tactics--specifically, messages that encourage people to adhere to a "no condom, no sex" philosophy. Given our results, future HIV prevention efforts would do well to refrain from advocating the use of this type of strategy with men, due to the potential among some men for angry or violent responses.

Results of this study also demonstrate individual differences and personal preferences in strategy evaluation, based in part on qualities of the message, but also on tone and value of the relationship. Thus, there was no "magic bullet"--there was no one strategy that all women or men liked universally (however, reward for men came close). This information is key if we are to increase the effectiveness of HIV risk reduction intervention models. Previous HIV intervention trials have shown outcomes reflective of HIV risk behavior change with new sexual partners, but no change with existing or long-term partners (Otto-Salaj et al., 2000). Participants in this study indicated differential assessment of strategy use by longevity and value of the relationship; if they valued the relationship, they often expressed a greater willingness to "go along" with strategies they might otherwise find distasteful. These results may help men and women to evaluate and predict, to a greater extent than previously able, the response of a partner to specific strategies; thus, they may be more able to tailor risk reduction skills to their situation, enhance condom negotiation effectiveness, and avoid negative outcomes. Realistically, there may occur circumstances when partner reaction is not the biggest issue: safety is, and use of a coercive strategy like "no condom, no sex" is important and appropriate. Thus, HIV risk reduction interventions should take these results into account and should try to train skills with good social impact and validity, but these data also will help us inform intervention participants as to what types of responses may occur, so they can make informed decisions about their sexual health. Finally, incorporating messages viewed as more effective by most of our participants through social marketing methods used in public service announcements or media campaigns may enhance their ability to assist people in effectively reducing their risk of HIV transmission through condom use.

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Support for this project was provided by National Institute of Mental Health (NIMH) grant R03-MH58522 and by NIMH Center grant P30-MH52776. The authors thank the 51 men and women who told us about their lives, and Carmen Ballentine, Lew Broyles, Jeff Buckles, Brenda Coley, Allan C. Hauth, Lori Runge, David Seal, Cheri Treffinger, and Cassandra Wright for their input and assistance.

Correspondence should be addressed to Laura Otto-Salaj, University of Wisconsin-Milwaukee, Social Work, Center for Addiction and Behavioral Health Research, P.O. Box 786, Milwaukee, WI 53201. E-mail: [e-mail]

Laura Otto-Salaj

Center for Addiction and Behavioral Health Research, University of Wisconsin-Milwaukee

Barbara Reed

Center for AIDS Intervention Research, Medical College of Wisconsin

Michael J. Brondino

Center for Addiction and Behavioral Health Research, University of Wisconsin-Milwaukee

Cheryl Gore-Felton

Psychiatry and Behavioral Sciences, Stanford University 

Jeffrey A. Kelly and L. Yvonne Stevenson

Center for AIDS Intervention Research, Medical College of Wisconsin