Determinants of multi-partner behaviour of male patients with sexually transmitted diseases in South Africa: implications for interventions.

This study aims to gain an understanding of the predictors of multi-partner behaviour among 2,233 male patients with STDs in Cape Town, South Africa. A structured interviewer-administered questionnaire was used. Questions were asked about personal determinants--i.e., biodemographics, general knowledge about STDs; beliefs and attitudes regarding STDs, perceptions of HIV risk; normative determinants including social norms regarding gender role beliefs about refusing sex and condom use behaviour as well as perceptions of self-efficacy in using condoms. The significant predictors of multiple-partner behaviour were identified through a logistic regression analysis. The majority of the patients were younger than 35 years and reported to have engaged in STD risk behaviours. The most significant predictors for multiple-partner behaviour are gendered beliefs that men's sexual desires are uncontrollable and gendered role beliefs about the appropriateness of refusing sex, negative attitudes towards condoms, being younger than 26 years old, and having had a previous STD. The findings suggest the challenge to address gender constructions in prevention interventions. This, however, requires a process of negotiated change by both men and women regarding gender constructions in support of the initiation and maintenance of HIV/ AIDS/STD preventive behaviours.

Key Words: STDs, HIV/AIDS, risk behaviour, gender

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Indicators of South Africans' exposure to high-risk sexual behaviour is present in the estimation that 4.74 million people are HIV infected and that approximately 11 million STD cases are treated annually (Colvin, 1997; National Department of Health, 2002). Improved treatment of sexually transmitted diseases has been found to reduce HIV incidence by about 40% in rural Tanzania (Grosskurth et al., 1995). The comprehensive management of STDs with equal emphasis on early diagnosis, treatment, and prevention, specifically directed at sustained behavioural change, has been widely advocated. Efforts directed at the prevention of STDs remain critical, focusing on achieving sustained behavioural change through reducing the number of sexual partners people have, all the while promoting sustained condom use (Royce, Sena, Cates, & Cohen, 1997).

However, the facilitation of sustained behavioural change remains problematic in South Africa. It has been argued that the AIDS pandemic is about women and inequity and that gender inequality where men are assigned a higher status than women is therefore fatal (Gupta, 2000). Within this context the practice of safer sex behaviours therefore greatly depend on men's commitment to it. While the empowerment of women remains a major HIV/AIDS prevention strategy (Johnston, 2001), it is possible that too few prevention efforts have been directed toward males as sexual partners (Campbell, 1995).

Men's, especially younger men's, relatively high level of multiple sex partner patterns ate supported by various studies in general and more specifically in Southern Africa (Brunswick & Flory, 1998; Dolcini, Coates, Catania, Kegeles, & Hauck, 1995; Mnyika Klepp, Kvale, & Ole-King'ori, 1997). Multiple partners have been found to be an independent risk factor in HIV acquisition (Morris, 1997). The traditional gender roles of males and females in South Africa are often blamed for existing gender inequalities that contribute to multi-partner behaviours and thus fuel the spread of HIV/AIDS and other STDs (Strebel, 1995). In men's traditional role, male sexual prowess is valued as an indication of men's ability to ensure the continuation of the lineage (De Villiers, 1992; Hadden, 1997; Wessels, 1996), while women's role is defined in terms of motherhood, fidelity, and a subordinate position in male-female relationships (Gupta, 2000; Meyer-Weitz, Reddy, Weijts, Van den Borne, & Kok, 1998; Ulin, 1992). A prevailing opinion is that consensual unions, often between a man and more than one woman, occur relatively frequently and are still accepted as normal cultural practices among South Africans in spite of the effects of modern life on many traditional customs (Harrison, Lurie, & Wilkinson, 1997; Mokhobo, 1989). The role of poverty in multi-partner behaviour with specific reference to sex work or sexual services in exchange for gifts is well documented (Colvin, 2000; Gupta, 2000; Mabitsela, Meyer-Weitz, Bosman, Marais, & Nkau, 2000; Meyer-Weitz et al., 1998; Mitton, 2000; Strebel, 1995; Ulin, 1992). Recent research on multiple partner patterns suggests that the prevalence of sexual and social networks is hampering efforts at reducing HIV transmission (Hankins, 1998).

It appears that men with higher levels of education have an increased risk of having multiple sexual partners because of the association of higher education with higher income that allows for more disposable income for social activities that may include casual sex and being attractive as a potential partner but also because of increased travel opportunities (Mnyika et al., 1997; Somse, Chapko, & Hawkins, 1993). The "sugar daddy" phenomenon where younger girls offer sexual services to older men in exchange for gifts is facilitated by the older men's higher socio-economic status, which contributes to multi-partner behaviour and an increased risk to contracting STDs and HIV/AIDS (Kelly, 2000; Shell & Zeitlin, 2000; Williams, Gouws, Colvin, Ramgee, & Abdool Karim, 2000).

Multi-partner behaviour in the absence of condom use greatly increases the risk of contracting HIV/AIDS/STDs (Dolcini et al., 1995). Condom use in South Africa is very low, with their use reported by about 10% to 20% of the population (Abdool Karim, Abdool Karim, Soldan, & Zondi, 1995; Abdool Karim, Mathews, Gutmacher, Wilkinson, & Abdool Karim, 1997; Colvin, 1997; Reddy, Meyer-Weitz, Van den Borne, & Kok, 2000). The obstacles to condom use in South Africa include negative beliefs and attitudes about condoms: the association of condom use with a lack of love and trust, which implies an association with promiscuity and even HIV/AIDS/STDs, as well as beliefs that condom use diminishes sexual pleasure and that condom use can even be dangerous (Buga, Amoka, & Ncayiyana, 1996; Colvin, 1997; Hadden, 1997; Kelly, 2000; Meyer-Weitz et al., 1998; Reddy et al., 2000; Varga, 1997). Many of the prevailing negative beliefs and attitudes about condoms ate grounded in gender constructions such as the perception that condom use results in a "waste of sperm." This notion implies that the expression of sexuality is motivated by the desire for and importance of procreation and is thus a clear illustration of how gender constructions impact negatively on condom use. Similarly, the unequal gender-power relationships between men and women in Southern Africa make it difficult for women to demand monogamy from their partners and/or to insist on their partner's use of a condom (Gupta, 2000; Meyer-Weitz et al., 1998; Varga, 1997).

Despite the fact that multiple-partner patterns have been generally accepted as a normal practice in Southern Africa, inadequate understanding exists on the psychosocial factors influencing multi-partner behaviour. This in itself is a major cause of concern, since an understanding of the determinants of male patients' multi-partner behaviours in the context of inconsistent condom use is an essential prerequisite for the development of interventions directed at STD and HIV/AIDS prevention. Against the background of the alarming incidence of STDs and the observed two- to five-fold increased risk of HIV infection among persons who have other STDs (Otten, Zaidi, Peterman, Rolfs, & Witte, 1994), the complexity of multi-partner behaviour poses major challenges to both health education programme developers and health authorities working in STD control. This study aims to gain an understanding of the predictors of multi-partner behaviour among male patients with STDs. Against the background of the above discussion, the study explored different determinants, namely, demographic variables (age, level of education, and employment status), knowledge about STDs, beliefs and attitudes regarding condom use, gender norms regarding sexual behaviours, and practices such as partner patterns and condom use.

METHODOLOGY

A quantitative study was conducted among 2,978 randomly selected Xhosa-speaking patients seeking STD treatment at primary health care clinics with dedicated STD services during November 1996 and February 1997 in Cape Town, South Africa. While only 35 patients refused to participate because they had either participated in previous research and did not want to do so again or were in a hurry and did not have time, five patients did not complete the interview due to the length of the questionnaire. The female patients (N = 745) were omitted for the purpose of the present study. It should be noted that because of women's subordinate position in relationships and their prescribed traditional role of fidelity, women would be more likely to underreport their own multi-partner behaviour.

A structured, interviewer-administered questionnaire was used. This research instrument was developed on the basis of a previous qualitative study, which investigated the psychosocial and contextual determinants of STD-related behaviours (Meyer-Weitz et al., 1998). From this earlier study the following issues emerged as influencing multi-partner behaviour, namely, patients' knowledge about the cause, transmission, and health effects of STDs; negative attitudes towards the use of condoms; and perceptions regarding normative gender roles. Additionally, Ajzen's (1988) theory of planned behaviour (TPB) provided insight into the personal (knowledge, attitudes, and beliefs) normative and perceived behavioural control determinants of behaviour that needed to be investigated. However, no attempt was made to test the theory. In order to ensure cultural sensitivity and valid/accurate data, a methodical questionnaire development process was followed through individual consultations and workshops. A final questionnaire with 103 questions was developed both in English and Xhosa. The interview lasted for about 60 to 80 minutes. The primary investigators were English-speaking.

MEASUREMENT AND SCALE CONSTRUCTION

Questions were developed in the broad categories of personal determinants: namely, biodemographics, general knowledge about STDs, beliefs and attitudes regarding STDs, perceptions of HIV risk; and normative determinants including social norms regarding gender role beliefs about refusing sex and condom use behaviour as well as perceptions of self-efficacy in using condoms. In addition, questions were formulated regarding practices such as communication with partners about the presence of an STD, the patients' STD history, and his partner patterns and condom use behaviour.

Both questions and statements were formulated to measure knowledge, beliefs, attitudes, and practices. Patients were asked to respond to these by indicating agreement or disagreement on the following response options: namely, "Yes," "Don't know," and "No" or in other cases only "Yes" and "No" to suit the vernacular of the participants' language. The number of the items was reduced to seven meaningful concepts based on content analysis of the items by the research team. The items related to knowledge and beliefs about STDs and condoms were grouped into six new variables. The items related to attitudes were grouped into one variable and those related to social norms and expectations were grouped into two variables. For the knowledge items all the "Don't know" categories were considered an incorrect response, and the items were recoded as follows: Correct = 1, Incorrect = 0. For the belief and attitude items, the "Don't know" categories were deleted. These items were recoded as follows: Positive attitude = 1 and Negative attitude = 0 (see Table 2 for more detail regarding scoring). Scales were constructed based on the summing of the items given a positive Spearman's correlation coefficient of rho = .65 or higher for variables consisting of only two items, and a Cronbach's alpha coefficient (Cronbach, 1951) correlation of . = 0.63 or higher for variables of more than two items. The minimum and maximum values of the respective measurement scales are depicted in Table 1. The scales, knowledge about STD prevention and cure as well as perceived seriousness of STDs, were excluded from further analysis owing to unsatisfactory correlation coefficients. An investigation for multicollinearity was done using SPSS Colliniarity Diagnostics (Tabachnick & Fidell, 2001). No multicollinearity was detected. The last root had a conditional index of 28.576; no dimension had more than one variance proportion of >.50. A description of the variables that emerged from the data used as measurement scales of the respondents' knowledge, beliefs, and attitudes related to STDs, condom use, and the valuing of gender roles in refusing sex and condom use is provided in Table 1.

FINDINGS

The data analysis was based on the 2,233 male STD patients. Frequencies were calculated for each item in the questionnaire, which included demographic variables such as age, education and employment status. Exploratory chi-square analysis was used to determine the association between these variables and multiple partners, previous experiences with STDs, and condom use behaviour. A chi-square analysis was done to determine the association between multiple partners and condom use behaviour.

To understand the variables (socio-demographic and other variables suggested by the theory of planned behaviour as well as the qualitative study) that may explain male patients' multiple partner behaviour and to assess the predictive power of the identified significant variables, a logistic regression analysis as an exploratory technique was conducted (SPSS Logistic regression, forced entry), with the number of multiple sex partners as an ordinal dependent variable (one versus two and more partners). The independent variables that were entered in the first step were the demographic variables, namely age, education and employment status; in the second step the three measurement scales related to knowledge and beliefs and the one measurement scale related to attitudes were entered. The independent variables related to social norms include the two measurement scales regarding the valuing of gender roles about refusing sex and using condoms as well as the belief that men's sexual desires are uncontrollable. Items related to self-efficacy with regard to condom use, i.e., perceptions regarding their ability to use condoms, and refusing sex while having an STD were also included. The independent variables related to practices that were included ate previous experience with STDs and condom use.

SOCIODEMOGRAPHIC CHARACTERISTICS OF MALE PATIENTS

The greatest proportion of the respondents fell into the age category of 21-25 years (39%). The respondents 35 years and younger composed 89% of the total sample, while the adolescent group alone (20 years and younger) composed 15% of the sample. With regard to the respondents' level of education, the majority (69%) had at least a secondary school education and should therefore be able to read and write. Twenty-three per cent of the sample had either a primary or no education, while only 7% had a tertiary education. Although the national unemployment figure was reported to be 36.2% in 1999 (Statistics South Africa, 2001), just over half of the patients (51%) were unemployed.

PATIENTS' SEXUAL BEHAVIOUR AND STD HISTORY

A substantial number (68%) of the patients reported having had multiple sex partners in the past six months. Among this group, 32% had had two partners, while 36% of the respondents had had three or more partners during this time. The patients who were in the 21 to 25 year age group and those who were unemployed were more likely to have indicated having had three and more partners in the last six months ([X.sup.2]] = 25; df6; p < 0.0001 and [X.sup.2] = 7; df2; p < 0.02 respectively).

The majority of the patients (58%) had experienced an STD previously. Of those patients who had had an STD, 44% indicated that they had had an STD only once in the past 12 months, 33% of the respondents had had one twice, and 23% had had one three or more times in the past 12 months. Those who indicated having had STDs three or more times in the past 12 months were more likely to have indicated having had three and more partners during the past six months ([X.sup.2] = 26; df4; p< 0.0001), to have indicated that they are employed ([X.sup.2] = 11; df2; p < 0.004), to be in the age group of 26 to 35 years old ([X.sup.2] = 30; df6; p < 0.0001), and to have a junior secondary level of education ([X.sup.2] = 16; df6; p < 0.01). Only 35% of the patients reported having used a condom in the past six months. The patients in the age group 21 to 25 year olds were more likely to have indicated not using a condom in the past six months ([X.sup.2] = 50; df3; p < 0.0001).

DETERMINANTS OF HAVING MULTIPLE SEX PARTNERS IN THE PAST SIX MONTHS

In an effort to find the most significant determinants of multiple sex partners, the logistic regression model that was fitted resulted in the identification of several variables as depicted in Table 2. From the personal determinants included in the model, it is shown that patients younger than 26 years old and those who had negative attitudes towards condoms were more likely to indicate having had two or more partners during the past six months than the others. With regard to the determinants related to normative gender roles, the analysis indicated that patients who believed that men are unable to control their sexual desires and who did not value gender role beliefs about the right to refuse sex were more likely to have had two and more partners during the past six months. The analysis further indicated that patients who had experienced STDs previously were also more likely to indicate having had two or more partners during the past six months.

DISCUSSION

From the data it appears that the significant determinants of multiple-partner behaviour of male patients with STDs ate contexualised in gendered beliefs that value sexual prowess in men. When considering the male patients' multiple-partner patterns, their experiences with STDs, and the low levels of condom use, the findings clearly suggest that for men, special prevention opportunities exist directed at sustained behavioural change. The urgency for intervention is further reflected in the relatively young age distribution of the male patients (54% of patients are 25 years old and younger) and the increased likelihood of this age group to engage in multiple partner behaviour as suggested by the data. This young age distribution is similar to the age distribution of HIV-infected people in South Africa (Abdool Karim et al., 1997; National Department of Health, 2002; UNAIDS & WHO Report, 1998).

Men's relatively high level of multiple sex partner behaviours is also supported by various other studies among men in general and more specifically in Southern Africa (Brunswick & Flory, 1998; Dolcini et al., 1995; Harrison et al., 1997; Mnyika, Klepp, Kvale et al., 1997). It has been argued that men and women have different goals for sexual behaviour (Kenrick, Neuberg, & Cialdini, 2002). The differences in attitudes toward casual sex has been reported to be one of the largest gender differences ever found (Regan, 1998; Wiederman & Hurd, 1999). In Southern African, sexual prowess is valued in traditional and current male gender roles while women are expected to be submissive to men's sexual needs (Gupta, 2000; Harrison et al., 1997; Meyer-Weitz et al., 1998). Although some progress has been made to improve the gender-power relationships between men and women, these notions of manhood and womanhood are still widely accepted by both men and women (Gupta, 2000; Harrison et al., 1997; Meyer-Weitz et al., 1998). While the majority of the male patients (68%) reported having had multiple sex partners in the past six months, 32% indicated that they only had one sexual partner during this time. It is possible that these men were reinfected by their partners who did not receive medical treatment as partner notification and treatment are major obstacles in STD management (Colvin, 1997; Mathews, Magwaza, Coetzee, Karpakis, & Grimwood, 1998; Reddy, Meyer-Weitz, Van den Borne, Kok, & Weijts, 1998). Another possibility is that the male patients were infected by their female partners. While it is not considered as "acceptable behaviour" for women to have multiple sex partners, women have reported to have multiple sex partners (Meyer-Weitz et al., 1998).

The data supports a strong linkage between multiple-partner behaviour and male gender constructions that value sexual prowess. The gender role beliefs that play a significant role in explaining men's multi-partner behaviour are the belief that men are unable to refuse sex because their sexual desires ate uncontrollable and the gendered role beliefs that it is not acceptable for men or women to refuse sex. This implies the existence of a perceived expectation that men should always want and be ready to have sex, while women on the other hand ate not expected to refuse sexual advances from males. This reflects existing notions that male sexuality is instinctive and uncontrollable (Meyer-Weitz et al., 1998; Reddy et al., 1999; Shephard, 1998), while women on the other hand should be submissive to men's sexual prowess (Meyer-Weitz et al., 1998). Women's real or perceived role in the maintenance or reinforcement of traditional male gender roles is unclear and needs further exploration. It is thus clear that gender constructions of both men and women, held by male patients with STDs, perpetuate multiple sex partner behaviour and men's consequent increased risk of STDs and HIV. In a study by Courtenay (1998) in the United States, it was found that young men who adhered to traditional male gender roles were more inclined to practice unsafe sex.

Furthermore, previous experiences with STDs were found to be a significant predictor of multiple-partner behaviours. It has been reported that for some men having an STD is synonymous with manhood since it reflects sexual prowess (Gupta, 2000; Meyer-Weitz et al., 1998). It is possible that this view underlies the abovementioned association. While it could be expected that previous experiences with STDs would have motivated patients to prevent future STDs because of the discomfort of symptoms, and possible exposure to preventive health education in which the risks of repeated STDs and HIV risk would have been pointed out, it is clearly not the case.

While it can be argued that multi-partner behaviour in the presence of consistent condom use should pose no serious risk to STD transmission and thus HIV infection, no significant relationship was found between the number of sexual partners and condom use behaviour. This differs from a finding in the study by Little, Myer, and Mathew (2002) in which a positive association was found between the number of sexual partners, recent condom use behaviours, and condom procurement. However, the study also indicated that individuals whose partners had negative attitudes towards condoms were less likely to procure condoms than individuals whose partners had positive or ambivalent attitudes towards condoms.

Negative attitudes towards condom use played a significant role in explaining STD patients' multi-partner behaviour. These negative attitudes centered around male gender identity constructs, i.e., the traditional male's responsibility to ensure the continued existence of the lineage and (related to this construct) the valuing of male sexual prowess. The negative attitudes related to the first construct include the beliefs that condom use is a waste of sperm because it will limit the continuation of the clan name and that it is bad because it is "like masturbation" and it is not "flesh to flesh." In relation to the second construct, the belief was held that condom use would cause a man to lose his virility. The influence of negative perceptions about condom use on its non-use has been supported by various other studies (Little et al., 2002; Meyer-Weitz et al., 1998; Varga, 1997). While condom accessibility has been reported to impact negatively on the use of condoms (Colvin, 1997; Gilmour, Karim, & Fourie, 2000), it seems not to be the case in this study. It is therefore stressed that the mere provision of condoms and of accurate medical facts about the value of condom use would not eliminate the underlying negative attitudes, located in gender constructions, towards condom use.

The findings suggest that the real challenge for preventive behavioural change lies in addressing gendered beliefs that emerged as significant predictors of multiple sex partner behaviour. These deep-seated beliefs touch the very core of what it constitutes to be a man and a woman within the Southern African context. While current research finds strong evidence for a biological (i.e., genetic, hormonal, and neurological) explanation for gender differences (Maccoby, 1998), social and cultural influences cannot be dismissed. Gender typing is thus seen as a result of interpretation, evaluation, and internalisation of socially transmitted ideas through a complex process of interacting influences on personal, social and environmental levels. This perspective explains the dynamic nature of gender ideologies, roles, and related behaviours, which in turn implies its potential for change through social learning.

With consideration of the limitations of the formal health care setting to bring about a profound change in the gendered beliefs underlying STD and HIV risk behaviour, the recent introduction of a gender sensitive approach to STD management needs careful consideration on a practice level. Within the health sector setting, a clear understanding of existing male gender constructions could provide untapped opportunities for preventive interventions. For example, some traditional notions of manhood that stress men's responsibility for the continuation of the lineage (De Villiers, 1992) could be viewed as relevant within the context of the AIDS pandemic. However, this would imply men's responsibility in the prevention of STDs and thus HIV infection but also their right to protect their own health and the health of their partners. This could be accompanied by the encouragement of, support of, respect for, and care for sexual partners. Central to a gender sensitive approach in STD management is the facilitation of open communication between partners. An awareness should be raised of and an open dialogue should be stimulated toward male and female gender constructions and roles that impact negatively on the physical and mental well-being of both men and women.

While male patients with STDs, and especially young males, constitute a primary target group for sustained behavioural change interventions, it should be noted that behavioural change strategies attempt not only to persuade people but also to enable individuals to adopt and maintain behavioural change within social environments supportive of this change. It is especially so if the behavioural determinants ate of a normative nature and contextualised within cultural values. This calls for an understanding by communities of how existing gender constructions fuel the spread of STDs but also require them to develop strategies to address effectively these gender issues. A social norm of gender constructions in support of the initiation and maintenance of HIV/AIDS preventive behaviours could thus emerge as a result of a widely negotiated change process.

Table 1

Instruments Measuring Knowledge and Beliefs toward STDs and Attitudes
toward Condom Use and Autonomy in Sexual and Condom Use Behaviour

                                          Number    [alpha]   Min./Max.
Measurements                             of items   /rho *     scores

Knowledge and beliefs

Knowledge regarding health effects of
  STDs                                      3       0.76         3-9
Beliefs regarding causes of STDs            3       0.63         3-9
Positive beliefs about condom use           6       0.74         6-18

Attitudes and social norms

Positive attitudes towards condoms          4       0.78         4-12
Valuing gender role beliefs about
  refusing sex                              2       0.71 *       2-6
Valuing gendered role beliefs about
condom use behaviour                        2       0.65 *       2-6

                                                 Standard
Measurements                             Mean    Deviation

Knowledge and beliefs

Knowledge regarding health effects of
  STDs                                    7.93     1.52
Beliefs regarding causes of STDs          5.22     1.81
Positive beliefs about condom use        14.06     3.17

Attitudes and social norms

Positive attitudes towards condoms        8.47     2.96
Valuing gender role beliefs about
  refusing sex                            4.29     1.80
Valuing gendered role beliefs about
condom use behaviour                      5.10     1.50

rho *--Spearman's inter-correlation coefficient

Table 2

Logistic Regression Analysis of the Determinants of Multiple Sexual
Partners in the Past Six Months *

Independent             Parameter     SE       Wald       P-value
variables **            estimates            statistic
                         (Beta)               df = 1
Men cannot
  control sexual
  desires                 -.480      .098     24.030      <0.001
Attitudes towards
  condoms                 -.053      .019      8.252       0.004
Valuing gender
  role beliefs about
  refusing sex            -.063      .028      4.807       0.029
Previous STD              -.436      .096     20.707      <0.001
Age                        .359      .102     12.314      <0.001

Independent             Odds     95% Confidence
variables **            ratio      intervals

                                 Lower    Upper
                                 limit    limit

Men cannot
  control sexual
  desires                .619     .511     .750
Attitudes towards
  condoms                .948     .914     .983
Valuing gender
  role beliefs about
  refusing sex           .939     .901    1.033
Previous STD             .646     .536     .780
Age                     1.433    1.172    1.751

* Those who have one versus two and more partners.

** Men cannot control sexual desires (No = 0, Yes = 1); Attitudes
towards condoms (positive attitudes = higher score, negative attitudes
= lower score); Valuing gender role beliefs about refusing sex (valuing
it = higher score, not valuing it = lower score); Previous STD (No = 0,
Yes = 1); Age (age <26 = 1, age >25 = 2).

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ANNA MEYER-WEITZ

University of Durban-Westville, SA

PRISCILLA REDDY

Medical Research Council, Cape Town, SA

H.W. VAN DEN BORNNE

GEPJO KOK

Maastricht University, The Netherlands

JACQUES PIETERSEN

PE Technikon, Port Elizabeth, SA

The authors would like to thank the Department of Health and Welfare, Western Cape, for access to STD clinics, and the Medical Research Council and Human Sciences Research Council for funding.

Correspondence concerning this article should be addressed to Arma Meyer-Weitz, School of Psychology, University of Durban-Westville, Private Bag x 51400, Durban 4000, South Africa. Electronic mail: [e-mail].

International Journal of Men's Health, Vol. 2, No. 2, May, 2003, pp. 149-162. [c] 2003 by the Men's Studies Press, LLC. All rights reserved.