Partner influence on noncondom use: gender and ethnic differences.

Women comprised over one quarter of all new AIDS cases in the U.S. in 2001, and heterosexual transmission of HIV was the main identified mode of transmission for women (CDC, 2001). Women report lower rates of condom use than males (Pugatch et al., 2000) and researchers note that condom use is complicated for women because the most common type of condom is worn by males (Simoni, Walters, & Nero, 2000). Gender differences have been found in factors such as attitudes toward condoms (Campbell, Peplau, & DeBro, 1992; Helweg-Larsen & Collins, 1994), intentions to use condoms (Morrison, Gillmore, & Baker, 1995; von Haefton, Fishbein, Kaspryzk, & Montano, 2000), attitudes toward buying or carrying condoms (Jadack, Hyde, & Keller, 1995), and negotiating condom use with a partner (Carter, McNair, Corbin, & Williams, 1999; DeBro, Campbell, & Peplau, 1994).

Another significant issue raised in regard to gender differences and condom use is that social norms and relatively fewer resources (e.g., lower incomes) may affect the power of women to control their sexual interactions with men (Amaro, 1995; Bajos & Marquet, 2000; Gutierrez, Oh, & Gillmore, 2000). Of concern is that power inequities lead women to acquiesce to noncondom use when they want a condom used but a male partner does not (unwanted noncondom use). This specific reason for noncondom use indicates a lack of power when powerlessness may be defined as engaging in activities because of the influence of a more powerful party (Emerson, 1962; Raven, 1992).

In qualitative studies with populations such as female injection drug users or females who are partners of injection drug users (Worth, 1989), women over 30 (Maxwell & Boyle, 1995), and women ages 16 to 21 (Holland, Ramazanoglu, Scott, Sharpe, & Thompson, 1992), male partners were identified as barriers to condom use. Quantitative studies with women have linked higher levels of condom use to perceived control over condom use

(Cabral, Pulley, Artz, Brill, & Macaluso, 1998); to "sexual power," defined as the expectation that the male partner would not get angry, violent, or refuse to have sex if the woman requested condom use (Gomez & Marin, 1996); to perceived influence over a partners' condom use (Kline & Vanlandingham, 1994); and to having a partner who did not resist condom use (Wingood & DiClementi, 1998).

However, in the above studies, Cabral et al. (1998) noted that only 5% of the women reported no control over their partners' condom use and over 70% of the women in Kline and Vanlandingham's (1994) study perceived they had a lot of power over their partners' condom use. On average, the women in Gomez and Marin's (1996) study thought their partners would probably not react negatively to a request to use a condom.

Kline, Kline, and Oken (1992) concluded that minority women often retain sexual decision-making power in relationships. Fullilove, Fullilove, Hanes, and Gross (1990) found that the low-income minority women in their study did not voice a fear of bringing up condom use with a partner, although the researchers felt it was still possible this fear did exist. Among a group of minority women, Harrison (1995) found that measures of resource power, such as education or employment, were better predictors of condom use than was power in their relationships. College females in Chan and Fishbein's study (1993) reported that telling a partner to use a condom was difficult, yet under their control.

In a study which included a male comparison group, Miller, Burns, and Rothspan (1995) found that 36% of the women and 28% of the men among African Americans in a community setting had at some time in the past received a negative response from a partner regarding using a condom. Gutierrez et al. (2000) found no gender differences among male and female adolescents in condom self-efficacy, defined as the perceived ability to discuss condom use and get a partner to agree to condom use. Dekin (1996) found that males perceived they had less ability to insist on condom use compared to females.

The above studies offer equivocal findings on whether women as a group are at increased risk of HIV infection because they lack power in situations where they want to use a condom but their partners do not. Most of the studies did not include a male comparison group, which would be necessary to support a claim that females are more vulnerable than males to unwanted noncondom use. Also, the studies most often examined the relationship between indicators of power (e.g., anticipated or actual partner reactions to condom requests, self-ratings of control over condom use, economic status) and overall levels of condom use rather than assessing the extent to which unwanted noncondom use occurs. The specific research questions this study examined were the following: To what extent does noncondom use occur because of a partner's influence (unwanted noncondom use), and to what extent might this differ by gender or ethnicity?

METHOD

Procedures

Participants were recruited from health classes in three ethnically diverse community colleges in Los Angeles County. The course, Principles of Healthy Living, is offered at all community colleges in California and is a requirement for graduation. Prior to administering the questionnaire, I held focus groups to ensure acceptability of the sexual language in the questionnaire and conducted a small pilot test to ensure that respondents understood the questions. These activities took place at nearby community colleges not used in this study.

All students in the classes were given a questionnaire and informed that they could leave the questionnaire blank or parts of it blank if they did not wish to participate. Students filled out the survey anonymously. This administration method has greater privacy and efficiency compared to other methods used to measure sexual behavior, such as telephone or face-to-face interviews (Catania et al., 1993). To minimize any reading problems, I read a consent form approved by an institutional review board, each question, and each response choice aloud to all respondents in each class at the same time.

Measures

The research instrument included questions on demographic characteristics, marital and dating status, and sexual history. The two specific questions on unwanted noncondom use were "Since age 16, how often have you had sex without a condom when you wanted to use one, but a partner didn't?"; and "With your current or most recent partner, how often do you/did you have sex without a condom when you wanted one used?" Participants were asked to select from the following responses: never, rarely, sometimes, often, or always. Another question, similarly phrased, asked about experiences with unwanted sexual intercourse since age 16. Since this is a more thoroughly studied area in which gender differences are well established, this question served as a check on the internal validity of the study. The survey instrument stated that for this study, the definition of sex or sexual intercourse was "when the penis is in the vagina."

RESULTS

Analysis

I calculated frequency distributions and means for the demographic data. Frequency distributions and percentages were produced for unwanted noncondom use since age 16, for unwanted noncondom use with the current or most recent partner, and for unwanted sexual intercourse since age 16. I also calculated these frequency distributions and percentages for each gender and ethnic group and for gender groups within ethnicities. I performed statistical tests for group differences after dichotomizing the data by those who had never experienced unwanted noncondom use and those who had.

Sample

Only the questionnaires of heterosexual students between the ages of 18 and 28 who had experienced sexual intercourse were analyzed to reduce variation in sexual behavior norms based on age or cohort. I also restricted analysis to those who immigrated to this country by the age of 10, as acculturation may affect norms of sexual behavior (Reynoso, Felice, & Shragg, 1993) and age at immigration may also affect norms of behavior (Landale, Oropesa, & Llanes, 1998).

After I excluded questionnaires of students not meeting the age, immigration, and sexual experience criteria, 284 questionnaires remained. Of these, 37 (13%) were not usable because they were blank or missing key information. I performed analyses on 247 valid questionnaires. Females outnumbered males in the data set 141 (57.1%) to 106 (42.9%), and there were 105 Latinos (42.5%), 68 African Americans (27.5%), 46 Whites (18.6%), and 28 participants of other ethnic backgrounds (11.3%). The average age of the students was 20.87 years. One quarter of the respondents reported they lived in below-average-income neighborhoods from ages 13 to 18, and 68% were from average-income neighborhoods. Overall, 78.1% of the participants were born in the U.S.

The average age of first intercourse was 15.7 years for males and 16.5 years for females. The mode for number of lifetime sexual partners was two to four partners for both males and females. Most of these young respondents (89%) were not married, but about two thirds indicated they had committed or exclusive relationships. The one third who did not have regular partners were most often dating casually, with the balance (12.2%) reporting they were not currently dating.

Unwanted Noncondom Use and Unwanted Sexual Intercourse

The responses to the question "Since age 16, how often have you had sex without a condom when you wanted to use a condom, but a partner didn't?" are displayed in Table 2. As seen in the first column of figures, just over half (53.3%) of the respondents reported they had never had this experience. Conversely then, nearly half (46.7%) of the respondents had experienced unwanted noncondom use due to a partner's influence since age 16. Overall, 27.2% said it had occurred rarely; however, 18.3% reported they had sometimes or often experienced unwanted noncondom use since age 16. Few of the respondents (1.2%) indicated that they always experienced unwanted noncondom use.

A somewhat higher percentage of males (56.2%) than females (51.1%) reported never experiencing unwanted noncondom use. Testing on these differences did not indicate they were significant. A significant difference was observed among the three main ethnic groups in the sample, with 63% of White respondents reporting they had never experienced unwanted noncondom use as compared to 56.7% of Latino respondents and 39.7% of African American respondents [chi square] = 7.259, df= 2, p = .027). Further tests of gender differences within each ethnic group were not significant.

Results for the second measure, "With your current or most recent partner, how often do you/did you have sex without a condom when you wanted one used?" are presented in Table 3. The overall pattern of responses for this measure was similar yet more moderated than that for experiences since age 16. Overall, 63% of the participants indicated they had never experienced unwanted noncondom use with their current or most recent partner; thus, the remaining 37% had. Over 20% (22.2%) of all respondents indicated that unwanted noncondom use had occurred rarely with their current or most recent partner. Over 10% indicated that unwanted noncondom use occurred with their current or most recent partner sometimes or often, and 3.3% reported they always had this experience with their current or most recent partner.

When I examined gender groups, I found that 65.9% of the females reported they had never experienced unwanted noncondom use with their current or most recent partner, compared to 59.0% of the males (ns). Among ethnic groups, 80% of White respondents reported they had never experienced unwanted noncondom use with their current or most recent partner, compared to 61.2% of Latino respondents and 58.2% of African American respondents. Once again, the ethnic group differences were statistically significant ([chi square] = 6.346, df = 2, p = .042). Further tests of the gender differences within each ethnic group were not significant.

Findings regarding the final behavior examined, unwanted sexual intercourse because of a partner's influence since age 16, did yield a decisive gender difference. Among females, 65.2% reported they had intercourse when they did not want to but a partner did, compared to 32.4% of the males ([chi square] = 26.021, df = 1, p = .000). Differences between ethnic groups were also significant, with 69.1% of African American participants, 50.5% of White participants, and 42.2% of Latino participants reporting unwanted intercourse since age 16 ([chi square]= 12.921, df = 2, p = .002). Tests on the gender differences within each ethnic group were also significant (African Americans, = 4.675, df = 1, p = .031; Latinos, [chi square] = 4.725, df= [chi square] 1, p = .030; Whites, [chi square] = 13.143, df = 1, p < .000), indicating that females within each ethnic group more often experienced unwanted intercourse than did the males.

DISCUSSION

In this study of a diverse population of sexually active young people, females and males were equally vulnerable to the influence of a partner who did not want to use a condom. Nearly half of all females and males reported unwanted noncondom use since age 16, and over one third reported this experience with their current or most recent partner. These findings are more consistent with research that has identified various factors, such as less interest in the relationship (Felmlee, 1994) or having alternative relationships available (Grauerholz, 1987), as predictors of power in relationships than they are with research that suggests gender is the most salient factor in power imbalances in sexual interactions.

The trend for African American and Latino participants to experience more unwanted noncondom use than Whites is significant because these ethnic groups are over-represented among HIV and AIDS cases (CDC, 2001). Reasons that these ethnic groups experienced more unwanted noncondom use may be related to cultural norms about sexuality or the groups' disadvantaged status in U.S. society, which limits access to high quality health and preventive health care services. Alternatively, particularly for African American participants, these higher rates of unwanted noncondom use may signal a higher awareness of the need for condoms. Previous studies have found higher rates of condom use (Laumann, Gagnon, Michael, & Michaels, 1994) and more positive attitudes toward condoms (Beckman, Harvey, & Tiersky, 1996) among African Americans.

The findings clearly indicate that HIV/AIDS prevention programs should include a culturally sensitive component aimed specifically at reducing or eliminating unwanted noncondom use for males and females. The current literature reflects little concern that men may not protect themselves when they desire to do so, except in the case of gay men (Kelly, 1995). Although females and males reported equivalent levels of unwanted noncondom use, research regarding gender differences in many aspects of condom behavior suggests that interventions may need to be gender specific.

The correct targeting and dosing of such a prevention component may be challenging. Although nearly half of the sample had experienced unwanted noncondom use due to a partner's influence, most indicated it did not occur frequently. However, for a small percentage of the sample, unwanted noncondom use did occur more often. This pattern may explain the varying findings of previous studies and indicates a need for individualized assessment of unwanted noncondom use risk. Any intervention should include a process for individuals to examine to what extent and why they engage in actions contrary to what they want to happen. The findings regarding ethnic group differences may indicate a need for interventions based on consciousness raising or group empowerment to complement individual approaches.

A limitation of this study is that it relied on self-report and recall. Although focus groups found students were willing to talk openly about sexual issues, using anonymous questionnaires may have encouraged respondents to divulge sensitive information, and the age criteria meant that participants would have fewer relationships and a shorter time period to recall, it is still possible that respondents had difficulty recalling their experiences, or denied or were unaware of the influence that others had over them. Also, although the sample size appeared adequate for statistical testing, tests of gender differences within ethnic groups may have lacked sufficient power. A study with a larger sample would clarify whether the observed gender differences in some of the comparisons within ethnic groups have any validity.

The method of surveying intact classrooms increased participation and likely reduced sample bias. If any sample bias existed, it should not have differentially affected gender and ethnic groups. However, community college students, even from lower income areas, certainly differ in important ways from those at very high risk for contracting HIV/AIDS (e.g., drug users). The possibility that systematic gender differences in unwanted noncondom use might emerge in other populations, especially clinical populations, should not be dismissed.

The search for ways to reduce the ever-growing representation of women among new cases of AIDS is of vital importance. The results of this study indicate that confronting the problem of control over condom use is one way to work toward this goal. However, to focus only on the powerlessness of women in condom conflict would be a short-sighted approach. Interventions need to focus on males, females, and the culturally specific needs of people from African American or Latino backgrounds to carry out the safer sex behaviors that they desire.

Table 1. Socidemographic Characteristics of the Sample

                                       N      %

Gender
  Female                              141    57.1
  Male                                106    42.9
Ethnicity
  Latino                              105    42.5
  African American                     68    27.5
  White                                46    18.6
  Other                                28    11.3
Age (Mean = 20.87, SD = 2.78)
  18-21                               175    70.9
  22-25                                48    19.4
  26+                                  24     9.7
Neighborhood income for ages 13-18
  Below average                        59    24.1
  Average                             168    68.6
  Above average                        18     7.3
Birthplace
  U.S.                                192    77.7
  Other                                55    22.3

Note. Percentages may not always add to 100 due to rounding; two
subjects omitted income data.

Table 2. Unwanted Noncondom Use Since Age 16 in
Percentage

                    Never    Rarely    Sometimes    Often    Always

Total               53.3      27.2       14.2        4.1      1.2
Female              51.1      31.2       12.8        4.3       .07
Male                56.2      21.9       16.2        3.8      1.9
African American    39.7      36.8       16.2        4.4      2.9
  Females           44.4      37.8       13.3        2.3      2.2
  Males             30.4      34.8       21.7        8.7      4.3
Latino              56.7      23.1       15.4        4.8      0
  Females           55.7      24.6       14.8        4.9      0
  Males             58.1      20.9       16.3        4.7      0
White               63.0      28.3        6.5        0        2.2
  Females           56.5      34.8        8.7        0        0
  Males             69.6      21.7        4.3        0        4.3

Note. Gender difference, ns, ethnicity difference, [chi square] =
7.259, df = 2, p = .027.

Table 3. Unwanted Noncondom Use With Current or Most
Recent Partner in Percentage (N = 243)

                    Never    Rarely    Sometimes    Often    Always

Total               63.0      22.2        8.6        2.9      3.3
Female              65.9      20.4        8.7        1.4      3.6
Male                59.0      24.8        8.6        4.8      2.9
African American    58.2      29.9        7.5        1.5      3.0
  Females           65.9      27.3        4.5        0        2.3
  Males             43.5      34.8       13.0        4.3      4.3
Latino              61.2      19.4       12.6        2.9      3.9
  Females           63.3      16.7       13.3        1.7      5.0
  Males             58.1      23.3       11.6        4.7      2.3
White               80.0      15.6        2.2        2.2      0
  Females           81.8      18.2        0          0        0
  Males             78,3      13.0        4.3        4.3      0

Note. Gender difference, ns, ethnicity difference, [chi quare] = 6.346,
df = 2, 042.

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Manuscript accepted June 23, 2003

Laurie A. Smith

California State University, San Bernardino 

Address correspondence to Laurie A. Smith, Ph.D., Department of Social Work, California State University, San Bernardino. 5500 University Parkway, San Bernardino. CA 92407.