Reasons for the adoption of celibacy among older men and women living with HIV/AIDS.

Early in the AIDS epidemic, the long-term sexual adaptation choices of infected individuals received little attention because cases were typically identified at an advanced stage of the illness, when debilitation was common and death was often imminent (Schiltz & Sandfort, 2000). Following the development of an antibody test that allowed earlier identification of infected individuals, research was directed at understanding whether these infected individuals were practicing safer sex and how to promote such behavior (e.g., Gold, Skinner, & Ross, 1994; Remien, Caraballo-Dieguez, & Wagner, 1995; Robins et al., 1994; Wiktor et al., 1990). With the recent advent of effective combination therapies (e.g., protease inhibitors), many infected individuals, including those at an advanced stage of infection, now enjoy the prospect of longer survival and a better quality of life. This, in turn, has enabled them to continue established sexual relationships or develop new ones. Although many of these relationships involve only safer sex practices, research on the sexual behavior of infected adults has continued to focus on sexual risk behaviors (e.g., Kalichman, 1999; Reilly & Woo, 2001; Semple, Patterson, & Grant, 2000) and on how the new treatments that can lower viral load to undetectable levels and enhance functioning may be implicated in a resurgence of unsafe sex, especially among gay men (e.g., Kelly, Otto-Salaj, Sikkema, Pinkerton, & Bloom, 1998; Vanable, Ostrow, McKirnan, Taywaditep, & Hope, 2000).

Given the strong focus on sexual risk behaviors, little is known about the full range of sexual adaptations HIV-infected individuals have chosen (Schiltz & Sandfort, 2000). Yet, extant research suggests that a significant minority of these individuals may choose to discontinue all sexual relations and become celibate for at least some period following their diagnosis (Adam & Sears, 1994; Siegel & Raveis, 1993; Wagner, Rabkin, & Rabkin, 1993). The circumstances or reasons for this decision are not well understood. As sexual satisfaction is often an important component of quality of life (e.g., Derogatis & Derogatis, 1990; Woodward, Hass, & Woodward, 2002) or associated with higher quality of life (Darling & McKoy-Smith, 1993; Giuliano, Pena, Mishra, & Smith, 2001; Laumann, Paik, & Rosen, 1999), understanding why some infected individuals choose this adaptation is important when options for safe sexual contact exist. To the extent that motivations for adopting celibacy are based on misinformation, lack of information, or irrational fear and anxiety, interventions may be useful in making celibate HIV-infected adults aware of and able to consider alternative adaptations that may be more satisfying and less socially isolating. The present study examined the reasons offered for celibacy among a sample of late middle-age and older adults living with HIV/AIDS.

Although 11% of adults diagnosed with AIDS are age 50 and older at the time of their diagnosis (Centers for Disease Control and Prevention, 2001), approximately 15% of all adults living with AIDS are 50 and older (Ory & Mack, 1998). In addition, a sizeable number of older adults are HIV-infected, but have not yet developed AIDS. As such, older adults comprise a significant minority of HIV-infected individuals. It is reasonable to speculate that infected older adults might have higher rates of celibacy due to disease and age-related factors. Older infected adults may be more inclined to adopt celibacy than younger infected adults because of a general societal attitude that HIV-infected adults should abstain from all sex, and similar negative attitudes that disapprove of older adults being sexually active (Bouman & Arcelus, 2001; Hillman & Stricker, 1996; Pratt & Schmall, 1989). As we could locate no research that examined rates of or reasons for celibacy among older adults with HIV/AIDS, below we review the prevalence and reasons for celibacy among three populations--healthy adults, HIV-infected younger adults, and healthy older adults--whose experiences may inform the understanding of celibacy among this group.

CELIBACY AMONG HEALTHY ADULTS

Very little research on celibacy has been conducted, perhaps because it is assumed to be a relatively rare phenomenon. Extant research, however, suggests otherwise. For example, a national survey of married persons (ages 16-90) found that 16% were sexually inactive in the prior month (Donnelly, 1993). Similarly, in a national sample of both married and unmarried adults (ages 18-59), 14% of men and 10% of women reported no sexual activity in the past year (Laumann, Gagnon, Michael, & Michaels, 1994).

Investigations into the factors associated with celibacy among healthy adults have identified several contributing variables. In a national sample of adults (ages 18-70+), age, gender, and marital status were associated with not having a sexual partner in the past year (Leigh, Temple, & Trocki, 1993). More specifically, adults ages 40 to 49 (11%) were more likely not to have had intercourse in the past year than were adults under age 40 (7%). More women (16%) than men (5%) had no sexual partners in the past 5 years. Furthermore, married adults (7%) or those living with someone (7%) were less likely not to have had intercourse in the past year than those who were separated (11%), divorced (21%), widowed (66%), or never married (13%; Leigh et al., 1993).

Psychosocial correlates of celibacy have also been identified. In a national sample of married adults (Donnelly, 1993), investigators found sexual inactivity in the prior month to be related to poorer relationship quality (i.e., lower marital happiness, higher probability of separation, and more arguments over sex), lack of shared activities with one's spouse, and having children (both a higher number of children and having preschoolers). Of most relevance to the present study, celibacy was also associated with older age (although only among men) and poorer health (Donnelly, 1993). In a qualitative study of involuntarily celibate adults, individuals reported that shyness, inability to relate to others, and a negative body image kept them from establishing sexual relationships (Donnelly, Burgess, Anderson, Davis, & Dillard, 2001). Contextual factors such as living with parents, working in sex-segregated occupations, and having no transportation were also reported as contributing to their celibacy (Donnelly et al., 2001).

CELIBACY AMONG OLDER ADULTS

Although aging is widely assumed to be associated with a declining interest in sex (Hillman & Stricker, 1996; White, 1982), studies of older adults have repeatedly demonstrated that although frequency of sexual activity does decrease with age, most older adults remain sexually active throughout their 60s and beyond (e.g., Leigh et al., 1993). Studies of primarily heterosexual U.S. adults showed that between 19% and 21% of adults ages 50 to 59 had been sexually inactive in the past year (Laumann et al., 1994; Leigh et al., 1993). These rates are very similar to those found among adults ages 18 to 29 (15-19%; Laumann et al., 1994; Leigh et al., 1993). In contrast, adults in their 60s generally have been found to have a higher prevalence of sexual inactivity (35-37%; Leigh et al., 1993; Marsiglio & Donnelly, 1991), but not in all studies (13%; Diokno, Brown, & Herzog, 1990). Although as many as a third of adults in their 60s have been sexually inactive in the past year, it is important to note that most older adults continue to have sexual relationships and sexual interest (Laumann et al., 1994).

While some studies have examined the prevalence of sexual activity and celibacy among older adults (e.g., Diokno et al., 1990; Leigh et al., 1993), much less attention has been focused on identifying the factors associated with celibacy among older adults. In analyses of a national sample of married adults restricted to those over age 60 (Marsiglio & Donnelly, 1991), sexual inactivity in the past month was associated with older age, a spouse's poor health, low self-worth, lack of shared activities, low relationship satisfaction, and longer marriages. Similar associations were also observed in the full sample, with additional factors such as the number of children and having preschoolers (Donnelly, 1993).

CELIBACY AMONG HIV-INFECTED ADULTS

Consistent with general population surveys, studies of younger HIV-infected men and women have reported a significant minority of celibate individuals. For example, in one study of primarily gay infected men (mean age 36), 19% reported no sexual partners since diagnosis (Wenger, Kusseling, Beck, & Shapiro, 1994). In another, 20% of gay men (median age 39) had been sexually inactive during the past year (Wiktor et al., 1990). Somewhat higher rates of celibacy have been noted among samples including both men and women. Between 31% and 38% of samples of younger men and women (average ages 39-40) with HIV have reported no sexual activity in the past 6 months (Reilly & Woo, 2001; Wight et al., 2000).

It should not, however, be assumed that HIV-infected individuals are more likely to be celibate than uninfected individuals. For example, in a study of younger gay men from New York and Washington, DC (average age 39), no significant difference in the rate of celibacy in the past year was found between HIV-infected men (20%) and uninfected men (10%; Wiktor et al., 1990). Similarly, no differences in the prevalence of celibacy were found between HIV-infected (23%) and uninfected (25%) gay men from a European cohort (average age 37; Wiktor et al., 1990). Still, among younger infected adults who are celibate, HIV appears to be a factor in their decisions to abstain from sex (at least among gay men). Among the subgroup (19%) of a primarily gay male sample (average age 36) who did not have a sexual partner since their diagnosis, 74% attributed this to their HIV diagnosis (Wenger et al., 1994).

Although some studies of HIV-infected adults have reported the prevalence of celibacy, few have examined its predictors. Among a sample of HIV-infected men and women (average age 40), the absence of any sexual encounters in the past 6 months was associated with lower income (less than $15,000), not living with a spouse or partner, obtaining care at a public clinic rather than a private clinic, and older age (Reilly & Woo, 2001). Another study of HIV-infected gay men seeking treatment for depression found that sexual abstinence was associated with greater hopelessness, being at a later stage of illness (i.e., having AIDS), and having a lower CD4 cell count (Wagner, Rabkin, & Rabkin, 1993), but not with the level of depressive or anxious symptoms, relationship status, or age.

Two qualitative studies have also investigated the reasons offered by younger HIV-infected adults for choosing celibacy. In a sample of HIV-infected men and women, the most frequently offered reasons for celibacy included a lack of desire for or an active dislike of sex, fear of transmitting the virus, fear of rejection by potential sexual partners after disclosing, fear of meeting new partners, fatigue or other symptoms which made sex difficult, and difficulty introducing safer sexual behaviors into an existing sexual relationship (Adam & Sears, 1994). Among both HIV-infected and uninfected gay men (average age 36) who had been celibate for the past 6 months (Siegel & Raveis, 1993), reasons for celibacy included believing that all sexual activity carries some risk of transmission, feeling that sexual activity was too emotionally distressing, desiring more from a relationship than just sex, feeling that safer sex was too much work, and believing that sex was an addiction and therefore they were likely to engage in sexual excesses if they did not abstain entirely.

In summary, the literature on celibacy among younger adults, older adults, and younger HIV-infected adults suggests several potential reasons for celibacy, including older age, gender, partner status, physical health, fear of transmitting the virus, and fear of rejection. Because late middle-age and older adults living with HIV/ADS posses many of these characteristics, celibacy may be a relatively frequent adaptation among this population. Extending prior qualitative work on celibacy among HIV-infected adults, the present report focuses on late middle-age and older adults (i.e., age 50 and older). We examined the reasons these older adults offered for their celibacy following their HIV diagnosis. Our results highlight the influence of gender on celibacy.

METHOD

Participants

The present study is based on data from a subsample (n = 30) of adults from a larger study (N = 63) that investigated the psychosocial adaptation of adults age 50 and older living with HIV/AIDS. The subsample consisted of individuals who were currently celibate or had been celibate by choice for at least 2 months at some point following their diagnosis. Rather than asking participants to self-identify as celibate, classification of participants as celibate was based on participants' descriptions of their behavior. Although some past research has defined celibacy as the absence of sexual activity for 6 months or more, we chose to narrow this period to 2 months because celibacy among this sample was purposeful rather than involuntary, and those who had recently chosen celibacy would have been needlessly excluded. However, the vast majority of the celibate subsample (90%) had been celibate for 6 months or more. Consistent with our definition, participants were included if they had been celibate for at least 2 months at some point following their diagnosis, even if they were no longer celibate. Not included were those who were abstinent either because they had been unable to find a willing partner or because they had been too ill to engage in sexual activities. Although some past research has focused only on the absence of intercourse, in recognizing that physical limitations on intercourse may exist in a medically ill population, we have chosen to broaden the conceptualization of celibacy. Individuals were considered celibate if they had abstained from intercourse and any other intimate contact with another person intended to achieve sexual arousal or gratification. Thus, if two partners hugged to emotionally comfort or support one another, but no indication was given that this contact was initiated for sexual arousal or gratification, it was not considered sexual activity. As such, participants who continued to have emotional relationships with a partner were considered celibate if they were no longer sexually involved.

Individuals were eligible for participation in the larger study from which the present sample was drawn if they (a) tested positive for HIV antibodies; (b) were 50 years of age or older; (c) attributed their infection to either sexual behavior or intravenous drug use; (d) were either African American or White (non-Hispanic) and born within the U.S., or if Puerto Rican had resided in the U.S. for 4 years or more; and (e) were cognitively competent as assessed with a brief screening measure (Katzman et al., 1983). The sample was restricted to those who attributed their infection to sexual or drug use behaviors because these modes of transmission accounted for 98% of AIDS patients 50 years of age or older in New York City at the time of data collection. Further sample selection was guided by the principles of representative case sampling (Shontz, 1965). In this method, participants are not selected randomly or by convenience; rather, they are chosen because they are judged to be representative examples with respect to the phenomenon under investigation. Thus, while eligibility criteria set the broad parameters for inclusion, beyond these criteria we selected participants to ensure the sample had considerable variability on time since diagnosis, disease stage, age, race and ethnicity, and gender, because these characteristics were believed to have potential influence on participants' psychosocial adaptation to HIV/AIDS.

From the full study sample of 63 late middle-age and older adults, 30 (48%) reported that they had been celibate for at least 2 months at some point following their diagnosis with HIV/AIDS. Most had been celibate for much longer. Only 3 individuals (2 women and 1 man) had been celibate for less than 6 months, with the remainder (90%) having been celibate for more than 6 months. Three other participants in the full sample were currently celibate, but had become celibate prior to their HIV infection and for reasons unrelated to HIV/AIDS, and therefore were excluded. In the full sample, women reported celibacy more frequently than men (78% vs. 36%), [chi square] (1, N = 63) = 9.19, p = .002. Although the ability to detect significant differences may have been limited by the small sample (N = 63), no significant differences were found between the celibate and non-celibate subsamples in age, race and ethnicity, sexual orientation, income, employment status, relationship status (married or have a steady partner or not), living arrangement (living alone or not), stage of illness, length of time since diagnosis, number of physical symptoms, or CD4 cell count.

The celibate subsample consisted of 16 men (53%) and 14 women (47%) between the ages of 50 and 68 years (M = 57.03, SD = 5.78). The ethnic-racial composition of the subsample was 43% African American, 23% Puerto Rican, and 34% White (non-Hispanic). Almost half (47%) were single, with 40% either divorced, separated, or widowed, and 13% currently married. The median household income was between $5,000 and $9,999 per year, with 90% reporting incomes less than $20,000 per year. Most (80%) were no longer working (largely due to their illness, 69%). Thirty-seven percent had a high school education or less, 47% had some college education, and 17% had a college degree or more. Over half (57%) of the sample self-identified as completely heterosexual, 37% as gay men, and 7% as bisexual men. Twenty percent reported histories of intravenous drug use. Thirty percent of the sample was HIV asymptomatic, 20% was HIV symptomatic, and 50% was classified as having AIDS (Centers for Disease Control and Prevention, 1992). Participants reported an average of 10 HIV-related symptoms (SD = 7.0, range = 0-22 of 27 possible) and an average CD4 cell count of 417 (SD = 339, range = 40-1,521). The participants had tested positive for HIV as little as 4 months to more than 11 years before study participation (M = 6.29 years, SD = 3.47 years).

Procedure

Participants were recruited from a number of community-based health and social organizations, support groups, advocacy organizations, and drug treatment centers in New York City. Flyers about the study and how to contact the researchers were posted within the organizations, and in some cases staff directly offered flyers to potentially eligible clients or members. To preserve participant confidentiality, the study relied on self-referrals. Researchers never asked recruitment sources to provide the names of their clients or members. Interested individuals were asked to contact us by telephone using the number provided in the flyer.

We screened individuals for eligibility by telephone. Eligible individuals wishing to participate were scheduled for an interview at the investigators' research offices. Puerto Rican participants were given the option of completing the interview in either Spanish or English. After giving written informed consent, each participant completed a semistructured interview (typically completed over the course of two meetings, each lasting approximately 2 hours) with a master's-level clinical interviewer. At each meeting, participants were given $25 and reimbursed for transportation costs. We conducted interviews from the fall of 1996 through the fall of 1997.

Interviewers used an interview guide that covered a variety of topics related to living with HIV/AIDS. The guide was not used as a structured interview schedule, but rather as an outline of topics of potential theoretical importance to be covered in the interview. Interviewers were encouraged to pursue issues raised by the participants that were not included in the guide. They were also trained to use the participants' comments, when possible, as a natural bridge from one topic area to another. Interviewers were trained to phrase questions neutrally and broadly to allow the participants to address questions from their own frames of reference. Further details regarding the recruitment, sample selection, and interview methods are available in previous reports from this study (e.g., Siegel, Dean, & Schrimshaw, 1999).

One topic area covered by the interview guide was the participants' sexual relationships and behaviors. Participants were asked about their recent sexual behaviors (since diagnosis, in the past 2 years, and in the past 6 months) and if they currently were sexually active (even if their sexual activities did not include intercourse). When they reported no sexual activity, participants were asked how long it had been since their last sexual interaction, and the reasons for their sexual inactivity. When participants spontaneously used the term celibacy, we asked them to explain what they meant by celibacy. We also asked participants whether they thought their celibacy was due to their illness or their age. Responses to this series of questions comprise the majority of the data reported here. Interviewers also explored how the participants came to choose celibacy and how they felt about becoming celibate when these topics appeared important. In addition, discussions of their sexual activity arose spontaneously in other sections of the interviews.

Data Analysis

Interviews were audiotaped and transcribed for thematic analysis. Following a preliminary reading of the full interviews, we excerpted all material in the interviews related to the participants' current sexual behavior. A preliminary reading of this material revealed that many of the older adults chose to remain celibate following their HIV diagnosis. Following this insight, we read the extracted interview material again to identify those individuals who were currently or had been celibate for at least 2 months following their HIV diagnosis. As noted above, rather than asking participants to self-identify as celibate, we based determinations of celibacy on participants' descriptions of their behavior. This method resulted in the present subsample (n = 30). We achieved a 95% agreement rate in identifying whether participants were celibate according to the definition described earlier. We then returned to the full interviews of those found to be celibate to extract any further material that might offer explanations for why celibacy had been adopted. Two members of the research team independently read this extracted material to identify the reasons HIV-infected older adults chose to become celibate following their diagnosis. A high degree of agreement was found between the readers regarding each participant's reason or reasons for celibacy, with perfect (100%) agreement in identifying the reasons for celibacy among the women, and 78% agreement in the reasons for the men. Based on this reading, the two researchers conceptually grouped these reasons into a mutually agreed-upon set of codes or themes that represented the most frequently reported reasons. Finally, we selected direct quotations that best represented the participants' reasons for their celibacy in response to HIV/AIDS. We have chosen to present the data as a series of case vignettes while still highlighting the common themes of the group so the situational context of each individual may be better understood and the interrelationships among different reasons can be better appreciated. Because the analysis of themes revealed some important gender differences, we present the data for women and men separately.

The qualitative methods of sampling and analysis employed in this study were not suited to deriving reliable prevalence estimates of the various reasons offered for celibacy. Because of the semistructured nature of the interviews, the content and time devoted to various topics differed between participants depending on their own particular concerns. Therefore, as in past work employing this methodology, prevalence statistics for each reason have not been calculated. Rather, the goal of the present study was to generate insights into the reasons for celibacy among older HIV-infected adults.

RESULTS

In our analysis of the participants' narratives, several prominent gender differences emerged in the reasons offered for celibacy. Therefore, below we present the reasons offered for celibacy separately for men and women.

Reasons for Celibacy Among Older Women

Most of the women who were not sexually active had been celibate since first learning they were HIV-infected. Although the circumstances leading to this choice and the reasons offered for it varied, there were a number of recurrent themes in their narratives. Most of the women, who all self-identified as completely heterosexual, expressed that they had experienced a loss of interest in sex since their diagnosis. Some actually appeared to exhibit a strong aversion to sex. Almost all spontaneously volunteered that they did not miss sex. Several felt that their choice not to be involved with a man had allowed them time to focus on themselves and their own needs rather than a partner's needs. Furthermore, the fear that they might infect someone else was a powerful deterrent to any sexual involvement, especially for those women who felt victimized by acquiring the illness from a partner who had concealed his infected status from them. Concerns about reinfection that might further compromise their health also figured prominently in many of the women's narratives.

A number of women linked their decision to refrain from sexual activities to the anger they felt toward the specific partner who had infected them and to the more general distrust they now had of all men. Typically, these feelings were the result of knowing or strongly suspecting that a partner had irresponsibly infected them. That is, he had known he was infected or at high risk but concealed that information from her. In other cases, these feelings were the result of having been abandoned by a partner once he had learned of her diagnosis.

A 50-year-old Puerto Rican woman who had been diagnosed 3 years earlier had been celibate since then. She felt betrayed by her partner whom she believed had infected her and then left her immediately following her diagnosis, despite initially promising to stay with her and care for her. Reflecting the rage she felt toward him, she remarked, "I never want to see him again because if I see him, I am capable of killing him."

Speaking later in the interview of the residual distrust and the fear that was the basis for her aversion to another sexual relationship with a man, she added,

   I feel that another relationship--I trusted this relationship,
   and I ended up with HIV. Somebody else can give me gonorrhea and
   I'll just get worse, and I will die from another disease. I don't
   have any more trust and I don't have time to give to another man.

She spoke too of her loss of all sexual feelings. Her language reflected the traumatic nature of her experience for her. She stated, "I passed through an experience that killed all of my desires. I'm numb." She was adamant about her disinterest in sex. She asserted, "I have never had sex since I discovered this [her HIV-infection] and I don't ever want to."

A 52-year-old White woman who learned of her infection only a few months earlier had abstained from all sexual contact since that time. She felt certain that she had been infected by her second (common law) husband, a man she had known for about 20 years and had been living with for 6 years until he was incarcerated about 10 months before the interview. Her second husband did not want to use condoms, always insisting that because neither of them was infected they did not need protection. She learned later that she was infected. After confronting him with her diagnosis, he confessed, "I'm sorry. I'm so sorry. I gave you the virus. I was afraid to tell you because I thought you would leave me, that I had it."

She commented that she was quite bitter about the circumstances leading to her infection and for a period was too angry even to talk about it. She confessed,

   You know, I hated him in the beginning. I used to stare at him and
   think of ways to kill him. And also, I mean, why did he hate me
   so much?.... He gave me death. The worst death there is. You
   should take a gun and pull the trigger it will be easier.

She did not foresee any future sexual involvements with other men because of her fear of infecting them. When asked if she would tell future partners about her HIV infection if she became sexually active again, she replied,

   I don't think I would have any future relationships with anybody
   else. I have opportunities now and I'm just not--not in the future.
   If I'm not with my husband, my current husband now, I won't be
   with nobody else. I would never want to infect somebody with
   this. No matter what protection or how careful you are, you can
   never be that careful, and it could just happen. And I wouldn't
   give this to nobody for nothing.

Similarly, an African American woman, age 52 and diagnosed approximately 3 months earlier, had chosen to become celibate. She believed she was infected by a man she was engaged to several years earlier. She reported that when she first told her current boyfriend, whom she had been with for about 4 years, that she had tested positive, "He held me and he reassured me that we were going to go through this thing together.... He kissed my tears away." Understandably, she felt quite betrayed when only 2 weeks later he stopped calling. Like the White woman noted previously, she insisted that she was no longer interested in a relationship with a man. She also discussed her diminished view of men in general, saying,

   You know, I have taken a vacation from them [men] and I'll tell
   you the vacation is warranted. It's so necessary for me to get
   into myself to know who [her own name] is and what she has
   done for herself so far. And the more I think about being alone,
   the less terrifying it's beginning to seem to me. The more complacent
   and happy and contented I can be with myself alone,
   without a man in my life.... I've always thought a man was
   the bigger, the stronger, the smarter, the sexier, the best. I always
   gave traits to the man and didn't look on myself as anything
   much. When in fact men are often not the smarter, not the
   stronger, not the wiser. Many times they don't have their act
   together. Look at what this one did to me, the last one.... Look
   at how he curdled at the wayside with problems that he could
   not deal with--a life problem. HIV is just another life problem.
   He could not deal with it.

Speaking of the benefits she derived from her choice to be celibate, she said,

   I have a sense of optimism that I wouldn't have if I was entangled
   with this man or that man. I don't see myself in a space in a time
   as I am now, I'm more focused on myself and the celibacy time
   that I am having is beneficial for me to let me take stock of who
   I really am and what I really want. And it let me put all the focus
   on me and it's very nurturing. It's very good. It's liberating to a
   point too to not need a man by your side every day of the week to
   define you as a woman when you within yourself.

Another 59-year-old White woman, celibate since her diagnosis 2 years earlier, learned that her partner of 3 years (now deceased) had AIDS when she took him to the hospital after he became very ill. A social worker there informed her that it was likely that her partner had transmitted the virus to her and strongly urged her to be tested. When she was tested, she was informed that indeed, she too was infected. At the social worker's suggestion, she told the boyfriend to go back to live with his mother since attempting to care for him could be detrimental to her own health. In her own mind she was unclear whether or not her partner had known he was infected when they were together. She reported, however, that he had stopped having sexual relations with her 3 months before she had taken him to the hospital and learned that he had AIDS, so she suspected that he knew something at least by that time, if not earlier. At the time, she had not asked for an explanation of his behavior, thinking perhaps he had simply lost interest in her.

She described her reaction to the news of his illness. She told us,

   I got real angry at first. I was visiting him in the hospital,
   right. And telling him, What the hell, you know. What didn't you
   know, what the hell. You know, like that type deal because ah,
   you know, just asking him. So mad at him, you know. Like I wanted
   to kill him....

This woman indicated she no longer had any interest in sex. Talking of her sexual urges, she described them as "since I got the virus, dead as a doornail." She commented,

   ... I just don't want to get involved in any kind of relationship
   at all. I'm not, ah, maybe it's my age or catching the virus with
   sex--I don't want no sex. And I'm old enough I can say I've
   done it all. You know, I don't really need it.

In explaining her choice to abstain, she spoke of her need to distance herself from any sexual feelings because of the stress it evoked. She said, "I'm just keeping myself away from the sexual part of my life." Later she added,

   It's just, I don't want to have sex anymore. I think getting the
   virus sexually just--that's it. I think that's really the real core
   of the issue.... You know, just think that I had feelings for
   [deceased partner], right. So that's why we were having sex....
   So I'm having sex with this person and look what I got out of it.
   So I think that's really messed up my brain sexually. And now I
   say I'm getting older, even though I know I'm not old enough to
   stop sex. But if I can handle it, I rather just handle it without
   sex. Because getting this virus I think sexually I just tries to,
   you know, I'm try to destroy that part of my body.... I think
   I'm really mad. I would say a vulgar word to you, but I won't.
   Only nice, but I think I am just fed up with the whole issue. If
   sex was the one issue that I got this, I don't want no part of it.

Like so many other women, a fear of reinfection was also a principal factor in this woman's choice to be celibate. She said,

   You know, as far as, you know, contacting or getting any different
   strain of the virus. Or also known that, claiming that you could get
   reinfected with another strain or get reinfected somehow, I think
   that's another reason too, that I'm not really too keen about sex.
   Because this is the reason I got the virus is sex, you know.

Finally, this woman remarked that she no longer even had the energy for sex. She said,

   I don't really feel I can really even have sex and maintain myself.
   I don't have that much energy. The little bit of energy I have, I
   want to do other things with. So I think that could be a motive too
   for the way I feel.

This woman, like many others, said that at this time she was not in a sexual relationship. The absence of a sexual relationship in their lives was something they valued because it allowed them to focus on themselves. She remarked,

   ... The virus has helped me a lot in its own way. It's helped me
   you know to slow down, to look after myself a little bit better, you
   know. So I'm okay with that part [not being in a relationship with
   a man].

Another African American woman, age 55, learned of her partner's infection about a year and a half earlier while taking him to the hospital for medical appointments that she did not know were HIV-related. On one visit to the hospital, a social worker, although not directly revealing the partner's diagnosis, asked her, "Have you considered testing [yourself] for HIV?" It was then she realized her partner was infected, that he undoubtedly had known for some time, but had not shared his diagnosis with her. She went for testing and learned she was positive. She explained that this caused her to lose all interest in becoming sexually involved again and she has been celibate since her diagnosis. She said,

   The fact that I don't trust no more getting into a relationship with
   anyone. I don't, I have no interest. That's another thing. I have no
   interest whatsoever with sex. I don't feel anything.

At a later point in the interview, she reported that becoming celibate was a decision she made after learning she was positive. She noted that fears of becoming reinfected or infecting someone else were, as with other women, principal deterrents to any sexual involvement. She said,

   I don't want to have sex with no one. Um, I don't want to catch
   nothing else from nobody. I don't want to give nothing to nobody.

Like most of the other women, she contended that she did not miss having sex. When asked what it was like to no longer have any sexual desires, she said, "You don't miss what you don't have ... I don't know. I just don't miss it."

Another 52-year-old African American woman had not had sex since learning she was infected 4 years earlier. She explained,

   I haven't had sex in 4 years. And due to this [HIV infection], that
   was my choice to be abstinent. I haven't even wanted anything.
   I've been afraid to be reinfected. And I also, I feel afraid of the
   stigmatism if I get with a negative person. I don't want to go
   through that stress and strain. I don't need it. It's not worth it.

Still, a year ago this woman met an HIV-infected man who was incarcerated. She had corresponded with him and they had plans to live together upon his release. She said she was very selective at this point in her life and would only consider sex with someone who shared her values and beliefs and whom she knew well. When asked if she and the man with whom she was corresponding will practice safer sex if they become intimate, she said,

   Definitely, yes. That's all we talk about. He wants the same things
   I do. He knows that--he doesn't want to do anything to harm me.
   He knows about the different strains and what can happen ... I'm
   definitely going to practice. I don't want to--I'm fairly healthy
   and I don't want to get reinfected. And I don't want to reinfect
   him because we have the same interest in it.

With two exceptions, all the women who had become celibate did so immediately following their diagnosis. One 53-year-old African American woman, diagnosed 6 years earlier, stopped having sex only about a year and a half year ago. She explained,

   I'm feeling the last couple of years, I have no desire for sex. Like
   um, that's like dead, you know. I don't even think about having
   sex, having a boyfriend, you know. I'm just trying to deal with
   myself because so much is going on with me right now.

When asked what she attributed these feelings to, she said,

   I attribute it to the fact that I had so much sex with so many
   different people. I also attribute it to menopause. As you get
   older, I realize a lot of people lose their sexual desire, you
   know. And the way my situation is now, I'm not with no man, and
   I don't feel I want a man in my life right now. I just want to
   try to deal with myself.

At a later point in the interview, she also mentioned that she would get constant yeast infections when she was having sex and this also made sex very unappealing to her. Again, the respondent expressed that she did not miss having sex. She said,

   It seemed like every time I had sex, something happened to me. I
   would have a problem. I would get yeast infection, itching and
   scratching and discharging. And it got to a point where I didn't
   want to be bothered, I didn't want to deal with it. And I felt
   like--I feel like I've had plenty of sex, I don't feel that I'm
   missing nothing at my age.

Like a number of other women in the study, this woman felt that focusing on herself and her health should be her priority at this time in her life. A sexual relationship was not only unimportant at this time but was also an unwanted distraction. She commented,

   At this point, I don't feel a man is a necessity, but I always
   thought I had to have a man. I don't feel that no more. I always
   felt that, you know, I couldn't do this by myself, or I couldn't
   do that. Now, I've found that I can do it. I don't have to have
   a man in my life.

Reasons for Celibacy Among Older Men

The reasons offered by the men for abstaining from sex were more varied than those offered by the women. As with the women, however, the fear of becoming reinfected and compromising their health as well as the fear of infecting others were commonly cited explanations for celibacy.

One 67-year-old White gay man who tested positive in 1987 after his partner of many years died of AIDS reported that he was celibate from 1983 until 1993. Before his diagnosis, he stopped having sex because he assumed he was infected and did not want to transmit the virus to anyone else. He recalled, "I was so terrified of giving it to someone else. Absolutely terrified." Afterward, his anxiety about the possibly of being reinfected with another strain of HIV or acquiring some other sexually transmitted disease further deterred him from new sexual relationships. He stated,

   See my doctor made it very clear to me and I hated him for it.
   Because I said to him, "Now that I'm HIV positive, can't I do this
   stuff?" And he started talking about the various strains. They start
   talking about the fact of other sexually transmitted diseases, if
   you're compromised, if your immune system is compromised,
   and you get any of that, you're in real trouble, you know. Measles
   could practically kill you.

After ten years of celibacy, this man started having encounters with a small number of people practicing safer sex. Eventually, he became uncomfortable with that and now has a companion whom he called his "buddy," with whom he has nonpenetrative sexual activity. He described their activities by saying,

   My buddy and I do play, it's play. It's two boys that don't really
   have erections, you know. Everything else but--so it's really--like
   kids with no penetration.

A 51-year-old Puerto Rican gay man who was diagnosed more than 7 years earlier reported that he had not had any sexual contact in over 2 years. Speaking of his abstinence and the reasons for it, he said,

   It's been a long time since I've [had sex]. That's why I go to
   church, to try to forget everything. I don't have anything, but
   sometimes you think about it. After all, I'm still young. I'm very
   scared. I feel that I can get reinfected or I'm going to infect
   someone else. So I'd rather stay like this and just live until God
   says so. I would like to have someone like everyone else would like
   to have. But if I find someone--well I can find someone if I wanted,
   but no!

Several men spoke of the guilt they believed they would experience if they had sex and placed others at risk of infection as a strong deterrent to sexual contact. A 53-year-old gay White man who had been diagnosed 11 years earlier related that after his diagnosis, he continued to engage in unsafe sex, but gradually moved toward celibacy because all other options simply evoked too much guilt. Discussing his evolution, he explained,

   I would have guilt problems [when engaged un unsafe sex after
   diagnosis] while having sex.... I was having a lot of guilt before,
   during and after. To put it in a nutshell, after a few years, I
   decided maybe I should really change my evil ways, and I decided to
   limit my activities to quote safe sex, unquote. And after that
   regimen for a couple of years, and realizing that there is no such
   thing as 100 percent safe sex quote, unquote, I decided celibacy
   was the answer. So that's what--with lapses--celibacy with lapses.
   I decided that's the approach. Less guilt this way.

Similarly, a 54-year-old Puerto Rican heterosexual male who had been abstinent for approximately 10 months since his diagnosis also worded greatly about the possibility of infecting others. He recognized that having sex would be so laden with guilt and anxiety that the stress associated with it could undermine his mental health, and through that, his physical health as well. He said,

   I'm 54 years old. I still get the urge. I can still perform,
   you know. I wish I could, but knowing where I stand and knowing
   what I have, I cannot allow myself to put anybody in a precarious
   situation. Somewhere down the line, with a counselor, I might be
   able to feel at ease with different methods of contraceptives and
   everything to give me some kind of security where I could possibly
   have a relationship with someone and to some extent without
   putting anyone in jeopardy. If I could, maybe I would. I don't
   know and I don't worry about it. Because I am too busy caring
   about my own health. The main part of my health is mental, and
   I wouldn't do anything to my mental state to jeopardize my physical
   health. And if I have to walk around with a mental state where
   I thought that in any way shape or form that I passed my status on
   to anyone due to my recklessness, I would definitely put a real big
   hurting on myself mentally which I know--I don't know, but I
   think--would jeopardize my health and chances, if I have any,
   about going through the pearly gates.

Although this man recognized the possibility of safer sex, he felt that having sex was "not worth the problem." He commented,

   With the little that I read, I understand that it is possible and if
   you go through the proper precautions, this and that. But who wants
   to go through all of these explanations and all of that. At this
   stage in life I could probably do without. That's not of my
   choosing. I say that only because I wouldn't wish this on nobody.
   And I couldn't find myself putting anybody in this danger. I would
   definitely have to be open and explain it. To find someone that
   would even be open too--that is too much to do. I could live without
   it at this point.

A gay White man who was diagnosed at age 65, 3 years earlier, also chose to become celibate following his diagnosis. He contended that he could not enjoy sex if he had to worry throughout it that he might infect someone. His age and the fact that he disliked using condoms were also identified as factors in his decision to abstain. He told us,

   When, as you get older when I, I can sort of fantasize and
   masturbate. I mean let's face it, how long can sex be, you know....
   You have to use condoms and I still don't like to use them. And I
   wouldn't be enjoying the sexual act because I'd be thinking that I
   could give it to somebody else, so it would be psychologically--it
   wouldn't work.

When asked if he would tell sexual partners about his HIV-infection if he became sexually active again in the future, he indicated that he would. However, he stated that the anxiety that notification would inevitably invoke in the potential partner would likely undermine the pleasurable mood of the encounter. He explained,

   Yeah, that's one of the reasons. First of all I would because I
   know how I would feel. The person's going to be so frightened, and
   they're not going to feel quite the same. So that destroys the
   whole feeling.

Along with a fear of infecting others or becoming reinfected, a number of the men also reported a diminished interest in sex or performance problems. One heterosexual 58-year-old African American man, diagnosed 7 years earlier, had separated from his wife approximately a year earlier because he felt he could not satisfy her sexually. He reported that since then, he'd had only one encounter in the past year, but apart from that had been completely abstinent for the last 4 months. His remarks suggested that his infection strongly undermined his sense of virility. He explained,

   Well, ah, I've always been a pretty positive person. I've always
   had a lot of confidence in me. When I got the virus, the longer I
   had it, the longer I had it, the less I felt like a man. Because
   one of the things it seems to do, at least it did to me is ah, is
   ah ah, I wasn't able to perform sexually. First of it, I was
   afraid because I didn't want to give it to anybody else. Okay. I
   was never one that used that protection in the past and it was
   hard to adjust to that, you know?.... And I felt like I was losing
   my size, and I was being less of a man ... and I could talk to her
   [his wife] about it.... And when I did get an erection, and when
   I was ready to go into a woman, I would think of, "What am I doing?
   Am I giving her the infection again? Or would I be getting her
   infection?".... I was just confused.

He originally attributed his performance problems to his age, but his physician discounted that. Then he believed the virus was responsible. He said his doctor told him, "That and your attitude about it, you know. What you're going through; how you're dealing with it. All of those things play a factor, you know."

The decision to adopt celibacy was not necessarily due to the absence of a sexual partner. One 64-year-old White gay man had been with his partner about 10 years. They had not had sex in almost a year and a half following his hospitalization. He contended that he believed he was the one primarily responsible for their inactivity. He remarked,

   I think that it's [abstaining from sex] my choice more than
   his perhaps. We haven't talked much about it.... Don't want to
   talk about it I guess. I don't know. And part of it, as [partner's
   name] would say, he doesn't even want to look at his own body.
   So I'm afraid to see him stripped. I'm afraid I wouldn't want to
   look at him and show some displeasure, some disgust to betray him
   in a way like that. And so maybe I'm avoiding, that is avoiding.
   And something I never thought was possible over the last year. I
   have since put a different emphasis on the need for sex. It's not
   as great as it was.

Another 61-year-old White man who described himself as "mostly homosexual" had not had sex in the nearly 4 years since his diagnosis. He spoke of the stress he endured caring for a partner who died of AIDS, and how detrimental the demands of being a caregiver had been to his own health. When asked if his being inactive had to do with age or HIV or both, he said,

   I think a combination, a combination of things. ! just, you know,
   HIV. Having HIV that wouldn't help much. So I mean then meeting
   somebody with HIV, then you get yourself in a whole--because
   I just finished taking care of somebody who passed with
   HIV. I'm not really keen on going through that again. I mean I go
   to [name of a facility serving AIDS patients] and I minister to
   them once a week, and I see, you know, those people who are
   already at the end of the cycle, if you want to refer to that. Ah,
   but that's basically as much as I want to get--and then I get
   involved with them as it is, for just one day of the week, and
   their problems, so you know.

A 53-year-old gay White man lost his partner of 30 years to AIDS in 1989. They both tested positive 2 years before that, but continued to have unprotected sex. He explained that the thinking at that time was that if both partners were infected it did not matter if safer sex was not practiced. He had, however, been celibate since his partner's death, except for three one-time encounters he had with men while traveling on business. He said, "I don't have sex because I'm so hung up about it." Later, talking again about sex, he said, "I don't have sex. ! would like to. That's a whole big problem that I have to work out."

He suggested somewhat later in the interview that during his partner's terminal illness, he had started to become a heavy drinker that led to physical changes that compromised his self-esteem and sense of attractiveness. He said,

   When he [his partner] was at the very end, when he was so sick.
   I would go out. The nurse would come to the house for about an
   hour. I'd just go out and have some drinks, And then I would
   get--I had started getting real heavy. And ah puffy--I didn't care
   about myself at all. I got very insecure about my looks, meeting
   people....

This man had been with his prior partner virtually all of his adult life and was obviously insecure about his ability to attract another partner. Speaking further about these apprehensions within the context of the New York City "gay scene," he said,

   It's this whole gay scene which is so, I don't know what word to
   use. Ah, it's snobby ... I mean here everybody wants the ideal
   person. And they'll find out one day that that doesn't exist. I mean
   it doesn't. But, ah, I just feel I can't, I can't compete. And I
   don't want to be like those people who go out there and kind of
   beg for it....

A 64-year-old "mostly heterosexual" White man who tested positive several years earlier reported that he continued to have unsafe sex for a number of years, but had now been celibate for more than 2 years. He described himself as "hypersexual" for many years before and after his diagnosis. Although primarily limiting his sex to women, he also reported some male partners. He attributed his current inactivity to the "the whole stigmatic factor, and also other people's fear" of the disease. He reported that he found most people were frightened of being sexually involved with an infected individual. He appeared to be no longer willing to suffer further rejection, however subtle. He commented,

   I wish that the disease itself wasn't a sexual one because then I'd
   fuck what I want to fuck. But I can't do that. I have to be out
   front. And then the fright wig goes up and I get that feeling,
   "Yeah as soon as the lady's out of here, she's out of here," you
   know. And I don't blame them. I don't blame them. Who would, you
   know. It still has all the stigma that anything sexually oriented
   would have. And so you are saying "do you want to have a trip with
   the dick of death and see whether I can protect you in an ongoing
   situation." And then I get, "Oh well, I wasn't really thinking
   about that".... And I've grown real tired of buying it, so I
   don't buy it.

Another 54-year-old Puerto Rican gay man who had been celibate since he tested positive almost 10 years earlier referred to himself as a "born again virgin." Like many others, his fear of contaminating someone else was a principal reason he offered for abstaining from sex. He remarked,

   You know, I think safe sex is no sex. When you can kill someone
   ... I find it ethically incorrect to want to risk the life of
   somebody else. I mean that's how I feel. So between the two,
   it's a clear choice for me, you know.

DISCUSSION

The present study identified the reasons HIV-infected late middle-age and older adults offered for choosing to become celibate. We found a number of similarities in the reasons offered by the men and women, but we also found several notable differences. Both men and women reported that fear of infecting others and fear of becoming reinfected were primary deterrents to any sexual involvements. At the time of diagnosis, not all participants recognized the additional risks associated with reinfection. Therefore, some continued to engage in unprotected sex. Only later, when they came to believe they could be reinfected with a different strain of the virus that would potentially hasten disease progression, did they decide to abstain from all sexual contact, fearing that even safer sex carded at least some unacceptable level of risk.

Another similarity was that a small number of men and women in the sample attributed at least some of the decline in their interest in sex to their age, believing that diminished sexual urges or drives were a normal concomitant of aging. The women who felt this way, however, tended to be younger than the men who shared these beliefs or attitudes. These late middle-age and older women may have perceived greater social pressure to reduce their level of sexual activity than did late middle-age and older men. Women might perceive a greater societal discomfort with being sexually active after age 50 than men, especially outside the context of marriage. In contrast, men may feel that continued sexual activity into their 50s and 60s is not only acceptable but expected. For both HIV-infected men and women, however, some recognition probably exists that the wider society may feel that since their illness can be sexually transmitted, they have a moral obligation to be more sexually restrained than they would be otherwise.

More striking than the similarities were the differences observed between the men's and women's explanations for celibacy. Notable in the narratives of several women was a deep anger and profound sense of victimization in instances in which they were infected by a partner with whom they had a relationship. This was especially characteristic of the women who knew or believed their partners were aware of their infected status but concealed it from them. These women felt deeply betrayed by men they trusted and angered by their deceitfulness. In a number of cases, the anger was better described as rage and was so great that the women had, at some point, felt a desire to kill their partners. Their anger toward the men who infected them typically was transformed into a general distrust of all men who sought a sexual relationship with them, making them wary of any sexual involvement. Most of the women who became celibate professed they lost all interest in sex or a relationship with a man, and insisted they did not miss it.

Among men, feelings of victimization and anger toward the individuals who might have been the source of their infection were virtually absent. The heterosexual men in the sample had presumably been infected primarily though intravenous drug use, while gay men had become infected through sexual activities. Consequently, the men generally did not blame others for their infection. Former drug-using men appeared to accept responsibility for the behaviors that led to their infection. None expressed any anger that someone with whom they shared needles might have concealed their HIV-infected status. Similarly, most of the gay men seemed to recognize HIV infection was common among the gay community and that they had chosen to engage in behaviors (e.g., anonymous sex, multiple partners, mixing drugs or alcohol and sex) that placed them at risk and probably resulted in their infection. As a result, the men seemed to feel considerably less victimized by their infection and less likely to see their illness as unjust.

Although a few men indicated that their interest in sex had waned since their diagnosis, others confessed they would prefer to remain sexually active, but judged the risks to their physical or mental health of doing so to be unacceptably high. Unlike the women, few men stated they did not miss sex. Instead, they were more likely to suggest that, although they still had sexual urges, they could endure them and do without sex. Given that they perceived potential costs associated with acting on those urges to be too high, they felt they had little choice. Their language did not suggest, however, as did the women's, that they actually experienced a kind of relief associated with not being in a sexual relationship. Interestingly, too, women were more likely to become celibate immediately following their diagnosis, while men were more commonly active for a period and only later ceased all sexual contacts.

Reading the narratives, one is left with the sense that the choice to abstain from all sexual involvements was more emotionally driven for women than for men. The women's language and the teariness with which many told their stories suggest that many felt hurt and violated by the men who infected them and very fearful of the additional harm--both physical and emotional--that could come from sexual contact with men. With the men, one had the clear impression that their choice to be celibate was usually the outcome of a reasoned decision-making process. Furthermore, although one woman did express a plan to become sexually active with a man in the future, most seemed quite strong in their resolve to forgo any sexual involvements in the foreseeable future. The men as a group seemed somewhat less resolved to remain celibate. The impression from their narratives was that if the risk of infecting others or becoming reinfected could be reduced to an acceptable level or eliminated, several would readily become active again. For the women, however, other barriers--emotional and psychological--would remain and might suffice to deter them from any sexual involvements.

The reasons for celibacy identified among these late middle-age and older adults living with HIV/AIDS mirror some of those observed in previous research on younger HIV-infected adults, such as fear of transmitting the virus, loss of interest or aversion to sex, and fear of rejection or stigma (Adam & Sears, 1994; Siegel & Raveis, 1993). Among the reasons for celibacy discussed here that appeared to be specific to older age were problems with sexual performance and negative feelings about their aging bodies (among men) and feeling that age was associated with a lack of sexual desire (among women).

The current study also identified an additional reason offered for celibacy. That is, both men and women reported a major concern regarding fear of reinfection with another strain of the HIV virus or another STD that might compromise their health. Previous research on celibacy among younger HIV-infected adults has not identified this concern. This may be because the possibility of reinfection with a different strain of the virus has only been recently recognized by infected adults as a potential and significant risk. Thus, if the study had included a younger comparison group, we might have found that they, too, would have offered this as a reason for celibacy.

The present study also differs from much past research in identifying gender differences in both the frequency and reasons for celibacy. Gender differences in the reasons for celibacy have not been previously identified among younger HIV-infected adults (Adam & Sears, 1994). Similarly, rates of celibacy have generally not differed by gender among healthy younger and older married adults (e.g., Donnelly, 1993; Marsiglio & Donnelly, 1991), although one study found that men were more likely than women to be sexually active at least once in the past 5 years (Leigh et al., 1993). The dramatic difference in celibacy rates identified here suggests the need for future research to examine potential differences in celibacy by gender, particularly among those living with HIV/AIDS.

These findings suggest that reasons for concern may exist regarding the mental health and quality of life of older HIV-infected adults who are celibate. Celibacy is one possible adaptation to being HIV infected that resolves some difficult interpersonal and psychological issues for individuals living with HIV/AIDS. It also precludes, however, the opportunity for healthy sexual relationships that may be psychologically beneficial. Celibacy may also be associated with greater social isolation, as one removes oneself from situations that may lead to sexual attractions. Additionally, women who chose celibacy out of distrust and who feel victimized may be at greater risk for psychological morbidity. Many of the women were harboring anger and resentment that became generalized to all men. Clearly, such attitudes are likely to interfere with the establishment of meaningful social relationships with men, even platonic ones. The findings also suggest that celibacy among both men and women is often chosen largely out of excessive fear (e.g., of transmission, reinfection, stigmatization, men). Therefore, the findings suggest that HIV-infected older adults may be in need of intervention to reduce or more realistically evaluate their fears of sexual involvement. Intervention goals may include helping them recognize ways they can safely become sexually involved or more therapeutic intervention to address and alleviate their feelings of victimization. In this way, HIV-infected adults, both older and younger, may be able to reestablish the psychosexual facet of their lives and perhaps improve their overall quality of life.

Limitations of the present study must be acknowledged. Given the small sample and nonrandom sampling procedures, it cannot be assumed that the reported prevalence estimates for celibacy or the reasons offered for this adaptational choice generalize to the broader population of older adults living with HIV/AIDS. Similarly, the small sample may preclude identification of factors other than gender (e.g., ethnicity, sexual orientation, time since diagnosis with HIV) which may influence rates of celibacy. Future research with larger and more representative samples are encouraged. Furthermore, the semistructured nature of the interviews (in which some participants spent a great deal of time discussing celibacy, but others spent relatively little) precluded accurate prevalence estimates for each reason. However, accurate prevalence estimates were not the purpose of the current study, nor were the methods employed appropriate to arriving at such estimates.

Despite the limitations of the present study, as the first study to examine the sexual lives of older adults living with HIV/AIDS, the findings offer an important initial exploration of celibacy among this population. These data add to the current understanding of the reasons HIV-infected individuals may elect to become celibate following diagnosis (a choice that clearly ensures they will not transmit the virus to others) and therefore has important primary prevention implications.

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Manuscript accepted January 15, 2003

This research was supported by a grant from the National Institute on Aging (R01-AG13379) presented to Karolynn Siegel, Principal Investigator. The authors also thank Alexis M. Canter for her assistance in extracting additional interview material. An earlier version of this paper was presented at the annual meeting of the American Public Health Association, Philadelphia, PA, November 2002.

Address correspondence to Karolynn Siegel, Ph.D., Director, Center for the Psychosocial Study of Health & Illness, Mailman School of Public Health, Columbia University, 100 Haven Avenue, Suite 6A, New York, NY 10032; e-mail: [e-mail].

Karolyn Siegel and Eric W. Schrimshaw

Columbia University