The impact of alcohol use on the sexual scripts of HIV-positive men who have sex with men.

There is substantial empirical evidence to indicate that as many as one in three HIV-seropositive men who have sex with men (MSM) report unprotected anal sex with HIV-negative or serostatus-unknown sexual partners (Colfax et al., 2002; Ekstrand, Stall, Paul, Osmond, & Coates, 1999; Kalichman, 2000; Kalichman, Weinhardt, DiFonzo, Austin, & Luke, 2002; Marks, Burris, & Peterman, 1999; Parsons & Halkitis, 2002; Parsons, Halkitis, Wolitski, & Gomez, 2003). Prevention interventions for HIV-positive MSM are urgently needed to reduce these sexual risk behaviors and prevent a resurgence of HIV infections among seronegative MSM (DiClemente, Wingood, del Rio, & Crosby, 2002; Wolitski, Valdeserri, Denning, & Levine, 2001), especially among MSM of color (CDC, 2000). In addition to potential transmission of HIV to sexual partners, HIV-positive MSM who engage in unprotected sexual behaviors risk infection with other sexually transmitted diseases and more virulent strains of HIV (Blackard, Cohen, & Mayer, 2002; Hecht et al., 1998). As such, it is important to better understand the sexual experiences of HIV-positive MSM so we can tailor interventions that are effective in reducing unsafe sex.

Alcohol use has been identified as a factor qualitatively related to unsafe sexual behaviors (Boulton, McLean, Fitzpatrick, & Hart, 1995). Quantitative studies of HIV-positive MSM have confirmed this connection between alcohol use and unprotected sexual practices (Dolezal, Meyer-Bahlburg, Remien, & Petkova, 1997; Kalichman, Kelly, & Rompa, 1997; Purcell, Parsons, Halkitis, Mizuno, & Woods, 2001). Other studies, however, have failed to demonstrate an association between alcohol use and unsafe sex among samples of MSM (Crosby, Stall, Paul, Barrett, & Midanik, 1996; Parsons et al., 2003; Weatherburn, Davies, Hickson, & Hunt, 1994). A recent review of event-level studies on the connection between alcohol use and risky sex found little evidence for a direct connection (Weinhardt & Carey, 2000). Others have found that other variables, such as outcome expectancies and sensation seeking, may play a role in predicting both unsafe sex and alcohol use (Gillmore et al., 2002; Kalichman, Heckman, & Kelly, 1996; Kalichman et al., 2002; Leigh & Stall, 1993).

Although alcohol use may not be causally related to unsafe sex, drinking may play a role in sexual scripts. Sexual scripts are the narrative ways in which people organize their beliefs and expectations regarding sexual behaviors. Script theory has been applied to a wide range of behaviors and scripting is a powerful metaphor for sexual activities. Based on the work of Gagnon and Simon (1973, 1987; Simon & Gagnon, 1986, 1999), sexual scripts can be examined from three levels: (a) the cultural level, in which scripts are constructed by cultural and social groups for the purpose of contextualizing acceptable sexual activity; (b) the interpersonal level, in which scripts govern the actual sexual interactions between individuals; and (c) the intrapsychic level, in which scripts are used to organize thoughts and feelings about one's own sexual behaviors and desires. These levels of scripting are intertwined but can be individually distinguished in terms of their salience in specific situations. For instance, the cultural level of scripts is likely to be most salient when the status quo is disrupted (e.g., an individual exhibits behavior that contradicts or clashes with what are considered to be socially desirable norms).

Sexual script theory uses a dramaturgical metaphor to frame behavior. Like the script for a scene in a movie or a play, a behavioral script includes very specific directions and cues which tend to include the who, what, when, and where for a sexual encounter (Gagnon, 1977). However the existence of behavioral scripts does not determine how each person will act out the script. Much like a scene script in a play, there is room for improvisation and for the actor's own contributions to the performance (Weis, 1998). Sexual script theory is a way of conceptualizing sexual behavior and can be used to amplify thematic findings by situating them within a broader framework. This perspective enables researchers to better understand how themes emerge--how people come to act and view their sexual actions in certain ways. Numerous researchers have applied script theory to analyzing various aspects of sexual behavior (Fordham, 1995; Muehlenhard & Rodgers, 1998; Sexton, 2001; Whittier & Simon, 2001), including sexual risk practices of MSM (Adam, Sears, & Schellenberg, 2000; de Zwart, van Kerkhof, & Sandfort, 1998; Diaz, 1998; McKirnan, Ostrow, & Hope, 1996; Mutchler, 2000; Seal et al., 2000).

A few of these studies have also used sexual script theory to frame behavior involving the use of alcohol or drugs (Fordham, 1995; McKirnan et al., 1996; Mutchler, 2000). These studies have shed light on the context of substance use as part of a script for socializing or for engaging in sexual behavior. These scripts involve expectancies for alcohol or drugs within specific social contexts. Contexts may involve a bar with loud music, a club where people go to dance and meet potential partners, or a bathhouse where men have anonymous sex with other men. Therefore, alcohol may be involved in scripts for different occasions (e.g., bar script, dance club script, or sex club script). These scripts include factors related to choice of partners, types of occasions, types of sexual acts, and decisions on whether or not to use condoms.

Moreover, different contexts elicit different alcohol expectancies and different reactions to inebriation (Fordham, 1995; Mutchler, 2000). McKirnan et al. (1996) have looked at the ways in which gay and bisexual men use alcohol expectancies, the pharmacological effects of alcohol, and scripts in their sexual encounters. First, alcohol results in a person focusing his attention on the present context, thereby decreasing his awareness of social norms 'or what is perceived as acceptable behavior (Steele & Josephs, 1990). Alcohol mutes self-monitoring and therefore increases the impact of environmental stimuli. Second, sexual scripts are enacted in response to strong situational cues and involve limited thought processing (McKirnan et al., 1996). The impact of this phenomenon on safety in sexual encounters, however, depends on what types of default scripts people have. lf a person has developed a sexual script that involves the use of condoms for anal intercourse, then the "automatic" aspect of scripting would increase the likelihood of protected sex.

In this research project, we sought to understand the role that alcohol use plays in the sexual experiences of HIV-positive MSM in terms of sexual script theory, using qualitative data from a racially and ethnically diverse sample of HIV-positive MSM with alcohol use disorders in New York City. It is important to note that human beings can construct different types of sexual scripts at different levels simultaneously (e.g., interpersonal as well as intrapsychic levels). For example, a person's thoughts and feelings about his interactions with others at the interpersonal level will assist in the development of scripts at the intrapsychic level. We explored this phenomenon through the qualitative results from the present study.

METHODS

Participants and Procedure

A total of 513 potential participants phoned for initial screening. Of these, 157 were excluded because they failed to meet eligibility criteria at the time of screening. Of the 356 eligible participants at screening, 253 men completed surveys and qualitative interviews.

To perform the qualitative analyses for this paper, we chose a subsample of 48 participants based on the following criterion: each participant had two usable sexual narratives, where one narrative reflected engaging in sexual activities under the influence of alcohol and another reflected engaging in sexual activities while sober. There were no differential effects between the subsample and the full sample in terms of venue where recruited, age, race or ethnicity, sexual orientation, employment, educational level, access to health care, CD4 count, viral load, AIDS diagnosis, quantity and frequency of alcohol use, recreational drug use, or HIV sexual risk behaviors.

We used two strategies to recruit participants: active recruitment, in which recruiters went into various gay and bisexual venues, approached men at random, described the study, encouraged participation, and provided phone numbers to enroll; and passive recruitment, in which written materials about the study were left in stores, AIDS service agencies, and other venues. The active recruitment efforts were based on a targeted sampling strategy designed to obtain systematic information because true random sampling was not feasible (Watters & Biernacki, 1989). Although targeted sampling cannot assure a representative sample, it can be used to enhance the degree to which the sample includes participants who come from a variety of backgrounds, reside within different social circles, and participate in gay, bisexual, and/or HIV/AIDS communities to varying degrees. Participants were actively recruited from two types of venues: AIDS service organizations and mainstream gay venues (e.g., bars, cafes, and streets in predominately gay neighborhoods). To protect against inadvertent disclosure of HIV status, each potential participant was given a project business card providing basic information about the study and was told "If this doesn't apply to you, please give it to someone you know." As a result, some men were enrolled in the study through friendship referrals or snowball sampling.

Participants were also passively recruited using tear-off flyers, study cards, advertisements in gay and mainstream publications, and through referrals from friends. Since MSM of color, particularly Black MSM, usually meet each other in their respective communities and do not access openly gay venues as often as their White counterparts (Boykin, 1996), the passive strategies were designed to supplement active recruitment efforts and facilitate enrollment of HIV-positive MSM of color who are typically less integrated into the community. Baigis, Francis, and Hoffman (2003) have reported that multiple methods of recruitment should be used to increase the likelihood that special target populations (e.g., MSM of color, non-gay-identified MSM) are adequately represented in studies with HIV-seropositive persons. We made substantial efforts to ensure that we obtained a racially and ethnically diverse sample. These efforts included specific targeting of venues serving the needs of HIV-positive MSM of color for both passive and active recruitment.

Men were screened by telephone to determine eligibility based on the following criteria: biologically male, self-identified as HIV-seropositive, reported sex with another man in the past three months, met criteria for alcohol use disorders, and age 18 or older. Individuals who were interested and eligible were then scheduled for an interview. At the interview, participants provided informed consent and then completed the self-administered survey measures and the qualitative interview. We paid participants $30. For the qualitative sample, 39.6% (n = 19) of the men were recruited from AIDS service organizations, 27.0% (n = 13) from mainstream gay venues, and 33.3% (n = 16) were referred by friends or other participants or via passive recruitment efforts.

Measures

The Alcohol Use Disorders Identification Test (AUDIT) was administered to all participants. The AUDIT is a 10-item self-report questionnaire that measures alcohol consumption, dependence symptoms, and personal and social harm reflective of drinking. The AUDIT has excellent psychometric properties and has been found to be superior to other self-report screening measures (Reinert & Allen, 2002). Participants were eligible for the study if their AUDIT score was 8 or greater, indicating the presence of an alcohol use disorder.

We used a critical incident measure (Leonard & Ross, 1997; Ross, Wodak, Miller, & Gold, 1993) to qualitatively assess contextual issues regarding the most recent episode of sexual activity with another man. Participants were asked to describe this incident in detail. Interviewers probed for information regarding when the incident occurred, where, with whom (primary or casual partner), what happened, the participants' mental state at the time, whether or not alcohol was consumed, and other issues as needed. A racially and ethnically diverse group of interviewers was trained to assist participants in providing sufficient detail so that a "picture" of the risk situation emerged. Such measures have been found to be useful in better understanding the contextual nature of HIV transmission (Leonard & Ross, 1997; Parsons & Vicioso, in press; Ross et al., 1993). Following the description of the most recent sexual incident, participants provided a second narrative, based on whether or not the first narrative involved alcohol consumption. For example, for participants whose most recent sexual incident was under the influence of alcohol, the second narrative was their most recent sexual incident while not under the influence of alcohol. Comparable probes and follow-up questions were used with the second narrative, and at the conclusion of the interview, participants were asked to compare and contrast the two sexual events.

Data Analyses

Participants' critical incident measures were treated as individual cases of sexual activity. Researchers of various racial and ethnic backgrounds followed a grounded theory methodology beginning with the analysis of a randomly selected subset of narratives. In keeping with the methods outlined by Strauss and Corbin (1998), we used themes identified in this first set of readings as codes whose validity depended on whether or not they were used and how reliably they were applied to the same sections of text by three lead members of the coding team. During this phase, we coded a set of transcripts using NU*DIST, a qualitative coding software program. In addition, we tested and modified the initial codes. Three members of the research team independently applied these codes to a subset of interviews (n = 12, 25%). We then used logistic regression analyses to examine the codes applied by the three independent coders and found that interrater reliability was high (Kappa = .92). Subsequently, we divided the remaining interviews among individual members of the research team for coding.

Once we had coded the critical incident measures, we framed the themes using sexual script theory. This theory enabled us to determine how the social meaning and organization of sexual behavior impacted these men's sexual activities and their narratives about these activities. The critical incident measures provided participants with a vehicle for retelling their experiences and an opportunity for both self-presentation and self-reflection. As such, participants' stories can be considered representational tools that may help the reader understand how people situate themselves within their social context.

RESULTS

Description of Sample

All 48 participants were HIV-positive biological males. The mean age was 38 (SD = 6.08) years and ages ranged from 22 to 61. The sample was racially and ethnically diverse, with 81.2% (n = 39) identifying as men of color. (See Table 1 for detailed sociodemographics.) Most participants (77.1%, n = 37) identified as gay or homosexual. The majority of participants (77.1%, n = 37) met the DSMIV criteria for alcohol dependence, while the rest were classified as alcohol abusers according to their score on the AUDIT. More than half (56.3%, n = 27) had been treated for alcohol abuse in the past, and 45.8% (n = 22) reported a history of drug abuse treatment. A third of the sample (27.1%, n = 13) reported some previous incarceration.

Participants had tested HIV-positive an average of 10 years (SD = 4.47) prior to the assessment, and the mean for the most recent CD4 count was 374 (SD = 271). For self-reported viral load, 27.1% (n = 13) reported an undetectable viral load and 12.5% (n = 6) reported that they did not know their viral load. The majority of participants reported not having an AIDS diagnosis (56.3%, n = 27), having some access to HIV medical care (89.6%, n = 43), and having some form of health insurance (85.4%, n = 41). Most of the participants (87.5%, n = 42) had at least a high school education or equivalent. Almost haft (45.8%, n = 22) reported some form of employment and 41.6% (n = 20) were on disability.

Overview of Qualitative Results

Alcohol expectancies were part of the sexual scripts. There were several ways in which alcohol facilitated sex for participants. Participants discussed the effect of alcohol on inhibitions, which enabled them to more easily interact socially and sexually. While many participants intentionally used alcohol to reduce their inhibitions, others viewed alcohol as having impaired their judgment about appropriate sexual behaviors. Whether intentionally using alcohol to facilitate social and sexual behavior or not, participants' discourse around alcohol was consistent with the literature on alcohol effect expectancies and on cognitive impairment (see George & Stoner, 2000).

As a result of analysis and coding of transcripts, we arrived at three basic types of sexual scripts involving alcohol that participants followed. They were routine, spontaneous, and taboo. These types of sexual scripts each operated across all three levels of scripts (cultural, interpersonal, and intrapsychic). However, different levels were more salient in certain scripts than in others. This is reflected throughout our qualitative results presented below. Verbatim quotes are included in the text, with the participant's race-ethnicity and age in parentheses.

Routine Sexual Scripts

Alcohol was commonplace in routine sexual scripts. Within this type of sexual script, drinking was part of a planned and conscious pattern. Participants were aware of incorporating the mood-altering and cognitive effects of alcohol into their preparation for meeting partners or potential partners, guided by interpersonal and intrapsychic sexual scripts. They reported that they drank to make themselves more relaxed during social and sexual interactions. Participants used alcohol within this type of script in two ways: as a social lubricant and as a prerequisite for sex.

Alcohol as a social lubricant. There were some participants who drank alcohol to facilitate social interactions. These participants felt less self-conscious and consequently more outgoing when they consumed alcohol.

   Even one beer sometimes makes me feel better, you know, and
   less shy, and things like that. So two beers, definitely I felt
   like, I don't know, well, in command of something, you know,
   willing t break the silence and approach someone. (African
   American, 38)

Some men talked about the use of alcohol to address issues regarding internalized homophobia. One bisexually identified participant described how alcohol helps alleviate his inhibitions about having sex with other men:

   I have a lot of inhibitions about sex and, naturally, drunkenness
   releases them. By the time I left the straight bar it was probably,
   you know, on my mind. Certainly by the time I got home it was
   very much on my mind. That's the only reason I wanted to go to a
   gay bar in the first place, because of the available sex. (White,
   52)

Another way in which alcohol played a social lubricating role was by diminishing the anxieties of some participants regarding how potential sexual partners might respond:

   I usually have to have, uh, have to have a little bit of drink
   inside of me to, to go over that, you know, first that they, how
   do you say, "fear" of who or how that person is going to react?
   (African American, 31)

In this passage, the participant is also implicitly referring to the types of scripts involved in meeting people, particularly new partners, for the first time. There are generally acknowledged patterns of approach and responses that typically provoke some level of social anxiety. This script also played itself out in the narratives of participants who described their first time at a new venue. For example, one participant described how alcohol impacted his decision to go to a bathhouse while on vacation:

   I think it did because if I'm sober I would never. No, let me see,
   even if I'm sober, send me to the baths when I'm sober, but I'm
   so used to that. But, going to a strange club in a new city for me
   --I think I needed to be high like that to get into it.
   (Latino, 34)

In another example, the following participant made it clear that opportunities for encountering sexual partners only occur when he has been drinking:

   I was like really, really, under the influence of alcohol. So it
   made me like really, really, friendly, outgoing, like lovey-dovey,
   and just doing everything. [laughs] You know, I have this phobia
   thing in my head about rejection. So, when people make passes at
   me, it's always been in a bar or leaving a bar. So, it always had
   alcohol to do with it. (Latino, 39)

Alcohol as a prerequisite to sex. In another scenario within the routine sexual script, participants drank with the clear intention of diminishing their sexual inhibitions, not just their social inhibitions as the previous participants explained. Participants drank specifically to set the mood for sexual activity as part of their sexual scripts at the intrapsychic level. Since they were seeking out sex intentionally, these participants felt that alcohol made them feel sexier and facilitated their sexual expressiveness.

In addition to drinking alcohol to feel more open sexually, participants also felt that alcohol added to the intensity of their sexual encounters. For many participants this meant feeling more aroused and sexually aggressive and, in some cases, resulted in the participant wanting to explore novel sexual experiences and organize his own thoughts and feelings about these experiences at the intrapsychic level.

   When you are drinking, you're open. When you're drinking, you
   know ... when you're drinking you're open. You can explore.
   You'll take chances. (Latino, 37)

   It was more um, wow, because we were drinking, you know what
   I'm saying, it was more, okay I want this [sex] now, kind of thing
   going, you know what I'm saying! I guess it was a little bit more
   wilder when we were both drinking. (African American, 34)

Some participants who stated that alcohol had become such an integral part of their sexual scripts questioned if they would ever have sex if they did not drink. These participants drank in order to put themselves in an affective and emotional state in which they could have sex-to put themselves in the "mood."

   Well, I wasn't exactly high. You know, I was a little tipsy. And,
   you know, to be very specific--if I didn't have a drink or two
   sometimes, 1 probably wouldn't have sex at all, you know?
   Because usually, you know, if one of the guys comes by to see me
   on the weekend, and, you know, we have a couple of drinks,
   that's, you know, that's usually the, the pre-, the pre-mood to it
   [sex]. I'd probably be celibate if I didn't have a drink every once
   in a while. (African American, 39)

There were some participants with routine sexual scripts who drank because of the perceived cognitive and behavioral effects of alcohol, viewing alcohol as a facilitator for lowering sexual inhibitions and leading to sexual activity. This serves as an example of how interpersonal-level scripting that includes personal interactions with lower inhibitions becomes intrapsychic-level scripting in which MSM regulate their own mood and inhibitions in anticipation of sexual encounters.

   Well, I fully went into the drinking and stuff with the intention
   of letting my, letting my inhibitions down completely.... If I
   hadn't anything to drink I probably wouldn't have done that [had
   sex]. Probably, it would not have been what it was. I mean, it
   might have been like I would have gone out with him maybe ate
   dinner with him or something like that. Maybe cuddled a little
   like that. But there would not have been any kind of prolonged
   sex or anything like that. (multiracial, 39)

The scripted use of alcohol as preparation for sex was part of intrapsychic-level scripting for a few participants who reported being engaged in sex work. One participant who engaged in sex work discussed alcohol use as a part of getting ready to have sex with a client:

   He gave me money and boom, we had sex. But at the part before
   we left I took a couple of more shots, you know to prepare myself.
   (African American, 44)

Alcohol for this participant was an important aspect of getting himself ready to have sex with a client.

Some participants discussed alcohol use as a routine prerequisite for sex with partners that they would not be interested in when not intoxicated.

   My friend comes over and I drink the alcohol. And we had sex-I
   mean it's just boring. It's like we're idiots. It's like
   rehearsed. He just comes over gets drunk and wants some head and
   that's it ... I was feeling pretty good, looking forward to getting
   high and drinking and stuff because it's a normal routine.... This
   is a drug and alcohol relationship and we have sex sometimes, he's
   not my friend, I don't consider him my friend. Just an acquaintance.
   (African American, 43)

It is unclear whether or not this participant's friend was "straight"-identified and just having sex because of the effects of alcohol. Regardless, the cultural level of scripts comes into play with these routine sexual scripts since both participants permitted themselves to engage in sexual activity with each other while they were under the influence. The effects of alcohol provided the context in which this type of behavior was deemed acceptable to both parties.

In these passages, and others like them, the participants discussed two aspects of alcohol use: (a) they know they would not have had sex or a particular "type" of sex without drinking, and (b) alcohol makes them physically and cognitively impaired--"sloppy" and unable to "know" what they're doing. Thus, for these participants, the expectation that alcohol would set the mood or get them psychologically ready (by causing cognitive impairment) was part of their routine sexual script, processed at the intrapsychic level. Other participants drank as part of the preparation for socializing. They drank ritualistically, incorporating their belief that alcohol would diminish their inhibitions in social interactions (i.e., interpersonal level of sexual scripts).

Spontaneous Sexual Scripts

In spontaneous sexual scripts, participants ascribed their sexual activities or their partner-selection choices to the effects of alcohol. What differentiates this type of script from the routine type lies in the participants' planning process. Participants did not intentionally plan sexual encounters and did not intend to meet a potential partner. Rather, participants felt that alcohol made them behave more impulsively than they would normally. However, for many participants, engaging in spontaneous sexual encounters is one part of a scripted pattern in which they engage in unplanned sexual encounters.

   I just kind of got a hair up my ass and kind of just like
   went out and just kind of bar-hopped.... I was out to be out.
   [Q: And you weren't necessarily hunting for something?] Yeah,
   right. I knew with my drinking that it would turn into that, but
   it wasn't, I didn't start out like that. I started out just
   getting out to get buzzed, and to drink. (African American, 38)

Alcohol played a role in these spontaneous encounters by making participants feel sexually aroused, making them more sexually adventurous and assertive, impacting their partner-selection criteria, and contributing to sexual compulsivity. These sexual scripts were developed at the interpersonal and intrapsychic levels, since participants were aware that alcohol would make it easier for them to potentially have new sexual encounters as well as to engage in sexual activity. These scripts could have been influenced by previous interpersonal encounters.

Alcohol increases sexual arousal. Participants described how, in spontaneous sexual situations, alcohol seemed to increase their sexual arousal and made them more interested in sex.

   Well after I had a couple of drinks, you know, I don't know about
   everybody else, but myself, I become more hornier. And usually
   when I do drink, most of the times when I drink, I get this rush. I
   gotta do something. And, since it was in a [sex] club and what not,
   the guy looked at me, I looked at him. We started talking. And one
   thing led to another--the next thing I know, he had his clothes
   off, I had mine off. (African American, 46)

In this passage the participant assessed his own state of being as a result of drinking. Alcohol was involved in scripting at the intrapsychic level. He also drew attention to scripting at the cultural level that promotes the free expression of sexuality.

In general, MSM visit sex clubs with the expectation to meet people and engage in sexual activity with someone. This expectation is part of the sex club culture. Sexual scripts are formed at the cultural level since the behaviors of sex club patrons influence what is acceptable or not. This participant seemed guided by sexual scripts at the cultural level while under the influence of alcohol in his sex club encounter.

Alcohol increases sexual adventurism and assertiveness. Other participants described how alcohol enabled them to be more assertive about their sexuality. These participants took more chances in terms of where they met partners, where they went to have sex, and what they did sexually. One participant described how alcohol use resulted in an atypical sexual encounter:

   That was a rare experience. First of all, I cruised somebody in my
   neighborhood in front of my house, that's unusual for me. Second
   of all, I invited him in my apartment, which was even more
   unusual for me. Usually I go to their apartment or basically, it's
   usually in their apartment or meet them some place. (Latino, 37)

In this passage the participant described a litany of behaviors in which he would not normally engage. The script guiding these behaviors was formed at the interpersonal level. Alcohol seemed to impact venue and partner selection. The participant met someone close to his house and brought him back to his home. Both of these behaviors allowed access to areas of his life that the participant seems to generally keep separate from his sexuality. Alcohol led him to violate what appear to be stable aspects of his interpersonal-level sexual script by altering where he met his partner and where he had sex.

Alcohol affects partner selection and sexual behavior Alcohol impacted partner selection through its effects on selection criteria in two ways. First, as described above, alcohol increased arousal. Second, it broadened the eligibility criteria for sexual partners, making a sexual encounter more likely. One participant, in talking about his recent episode of unprotected oral receptive sex under the influence of alcohol, explained how being drunk effects his partner selection choices: "I feel less picky, you know, less choosy" (Latino, 43).

Another participant, in talking about sex with his HIV-negative lover after they had both gotten intoxicated, reported the following:

   But we never really got to sex on Friday because we had a bad
   thing happen. Oh there was, but, we had the drinks, we kissed, we
   had some oral sex, I licked his ass. And in the heat of the
   moment I put my dick in his ass without a condom. And then we
   both got terrified and stopped everything and did not have any
   more sex. But it freaked us both out very bad, big time and it
   was the drinks you know. (White, 33)

This participant felt that alcohol played a role in he and his partner engaging in unsafe sex when they normally do not. In this scenario alcohol seemed to lead to the violation of the interpersonal sexual script the participant and his partner had established. This script involved the use of condoms for anal sex.

A general contribution of alcohol to intrapsychic- and interpersonal-level sexual scripts is the intensification of sexual pleasure. It is compelling to view this in light of a more general cultural-level script that unites alcohol with dating, romance, and sexual disinhibition. Some participants drank to overcome negative feelings they may have had toward their sex partners at the moment in order to have sex.

   We were not getting along and, 1 think we both wanted sex with
   each other, so we kept plying each other with alcohol. So, and we
   both, once we get past a certain amount of alcohol we are gonna
   have sex. (African American, 36)

Another participant involved in sex work talked about using alcohol to deal with negative moods and to help him to continue having sex, and later to have sex with a nonpaying partner.

   Well, I was lonely, depressed and I had turned two tricks. I was
   drunk from the beer. Each time I turned a trick, I bought more
   alcohol. Then I ran into someone that I knew from the past and we
   had never had sex before. But it was somebody I was familiar
   with--we were good friends, somebody I already desired previously.
   And I was drunk. I was sexually unsatisfied. And then I turned to
   drink, I was stimulated but I wasn't sexually satisfied. And we
   both agreed to buy some beers and have sex. (African American, 35)

This male sex worker drank not just to continue to be "stimulated" but also because he was depressed. He drank with a non-paying partner (someone from his past) to have more sex because, despite several "tricks," he was sexually unsatisfied at that point in the night. He integrated alcohol into his sex work script most likely at the intrapsychic level where, as in previous narratives, it played a role in organizing his own emotional state. In addition, being under the influence was part of his way of interacting with clients and other sex partners, a script that is processed also at the interpersonal level.

It is compelling to view this participant's story as indicative of a search that may have more to do with emotional longing than sexual desire. Alcohol facilitates contact with both types of partners--the paying and the nonpaying, familiar and unfamiliar. Drinking alcohol also assists in the search for continuous sexual satisfaction, similar to the continuous search for that first drug high experienced by many substance abusers.

Alcohol affects sexual compulsivity. In an extreme instance of the spontaneous sexual script, participants who felt their sexual behavior was compulsive or addictive often cited alcohol as part of that compulsion or addiction.

   Because it's something that clicks in when I'm drinking that
   I've very rarely been capable of controlling. You know, a Dr.
   Jekyl and Mr. Hyde. And the sex thing is truly a fantasy that
   I think of. I wish I probably never would have encountered it,
   because it's sort of like an addiction, although I control it
   sober. I have no control over it when I'm drinking. (White, 35)

Although it is difficult to tease out if this participant drinks in order to engage in sex or has sex because he has been drinking, what remains clear is that he feels that, when he drinks, his sexual impulses and desires drive his behavior. In this narrative, alcohol plays the role of catalyst, altering the participant's cognitive abilities and impairing his sense of impulse control. As is the case for other participants who employed the spontaneous sex script, the effects of alcohol lead to a sexual encounter by increasing sexual desire, broadening the field of potential partners and behaviors, and diminishing the participant's sense of control over his sexual responses. Within the spontaneous sexual encounter, alcohol alters participants' conscious intentions. Another participant revealed a similar pattern:

   Like I said, sex when I'm drinking, it's like an addiction ...
   With men, if they have a beautiful ass, it gets me every time.
   There's something uncontrollable that I feel that I have to go
   and have sex, you know, because of that fact, you know. And,
   whether I'm interested or not, I know that. I'm compulsive that
   way. (African American, 37)

The participant in this passage draws attention to ways in which alcohol can become integrated into an intrapsychic-level sexual script that revolves around heightened arousal and loss of control. This script incorporates the impact of alcohol on impulse control by means of its effect on arousal and triggering compulsive behavior. In this scenario the participant's intention, indicated by his interest in sex, does not predict his behavior; instead, his behavior is driven to compulsive sexuality and spontaneous encounters.

Taboo Sexual Thoughts and Behaviors

Alcohol enabled some participants to overcome guilt, fear, and anxiety regarding sexual behaviors that they felt were taboo, such as anal receptive sex (i.e., "bottoming") or infidelity. These participants felt that alcohol enabled them to discount their own moral, safety, and commitment boundaries. Participants discussed not only their own behavior in this regard but also the behavior of their partners. Some participants discussed going as far as thinking about intentionally transmitting HIV when they had consumed alcohol.

Delving deeper into the intrapsychic level of sexual scripts, some participants indicated that alcohol allowed them to have stigmatized thoughts. One participant highlighted how these might impact HIV sexual risk behaviors. In the following passage, the participant began by stating that his behaviors are riskier when he is drinking. However when the interviewer probed into what makes the behavior riskier, the participant referred to his thoughts:

   My behaviors are more risky. My sexual behaviors are more
   risky when I'm drinking. Because I do have this fantasy that
   I would love to come in your ass and I'm HIV. I would love to
   shoot this come in your mouth, but I still would never act out
   on it, but the thought has been there. (African American, 34)

In this excerpt, the participant differentiates between his thoughts and his behavior. He recognizes that when he drinks he often has a fantasy that involves ejaculating in his partner during sex. The cultural level of sexual scripting is salient here. The passage reflects the way in which he reconciles thoughts about ejaculating in his partner and potentially transmitting the virus, opposing the public health messages fostering responsibility among HIV-positive individuals to not infect their partners.

Many participants believed that they engaged in certain sexual behaviors due to the effects of alcohol. They did not drink to be able to engage in these behaviors; rather, they felt that drinking was the primary reason for ultimately engaging in the behavior. Participants were apt to ascribe such a role to alcohol when they felt the sexual behavior was taboo or stigmatized, such as in the case of anal receptive sex. Anal receptive sex carries negative connotations for many MSM (Wegesin & Meyer-Bahlburg, 2000), so in some cases the use of alcohol facilitates engagement in bottoming. One participant explained how alcohol led to his having anal receptive sex:

   I'm usually the top and I don't really give up ass. Or if I
   do, you're going to have to work for it because l don't roll
   over and give it to you. (African American, 38)

The language this participant used to describe his sexual encounters indicates the societal meaning attached to being the receptive partner in anal sex. For this participant, violating the cultural-level script that determines which partner penetrates and which is penetrated requires that he develop an intrapsychic script that uses alcohol to deflect the desire or responsibility for being the one who "rolls over" or "gives up ass."

Other participants described how alcohol use resulted in sexual behaviors going further than they had planned:

   We sucked each other, and he ended up fucking me without a
   condom. Actually, although I had hoped to have sex with him,
   I had hoped that it would just be--I didn't even want him to.
   I just wanted it to be like, I just wanted to suck him. I didn't
   even want to get undressed. I didn't want to get that intimate.
   But, it turned out, because of the alcohol, it didn't take much
   to turn into what it did. (Latino, 39)

   Oh when I got to his apartment he offered me a drink, which I
   didn't want anymore because l was drunk already. At first he
   wanted, at first he used a condom and then like he said--he
   claimed that it broke, but he didn't come or anything. Then he
   took it off and I just accepted it without, you know. Usually I
   would say that you can't go in me without a condom, but he was
   [HIV] negative. That was terrible of me to do that too, because I
   could infect him, you know? (African American, 37)

This last passage began with the revelation that the participant was already drunk when the sexual interaction began. He then indicated that he did not follow his typical sexual script by "accepting" that his partner was not wearing a condom. While he felt that perhaps this was due to his partner's HIV-negative status, he also felt that he could have infected his partner. For this participant, being drunk also meant being more passive. At the intrapsychic level the participant explained that he normally would engage in protected receptive anal intercourse, but alcohol contributed to this lapse and engagement in a taboo sexual behavior.

Some participants discussed the way in which alcohol, taboo behavior, and HIV transmission risks were sometimes combined in sexual encounters.

   We did oral blow jobs. I'm usually, I'm usually on top. I usually
   don't get fucked. But, because of where I was [reference to being
   under the influence], I was like, oh, fuck it. I'll probably never
   see this guy so I'll give him some ass. So we kind of, we didn't
   use condoms at all. (African American, 38)

The state of being drunk provides the cognitive space to allow oneself to act on an otherwise taboo behavior. The participant in the passage above gave in to the freedom afforded by this place (i.e., being drunk) and "gave up his ass." This passage highlights the important role that alcohol plays within the participant's sexual encounter and his narrative about the sexual encounter. He began by labeling himself a "top" and made a broad statement about his usual sexual practices before he described a specific encounter in which he bottomed. Before be revealed his anal-receptive sexual behavior, he mentioned "where I was" in order to contextualize his role in the sexual encounter. It may be the case that the impact of alcohol on unsafe sex behaviors is dependent on the role it plays in particular sexual encounters.

In addition to speaking about their own taboo behaviors while under the influence, participants also discussed their partners' behaviors. This was generally in the context of partners who were straight identified or were exclusive tops who claimed not to perform oral sex nor act as the receptive partner in anal sex. In explaining how alcohol impacted an encounter, one man said:

   That had a very marked effect on things because he, he's,
   see he's a married man, and I think that sometimes, you know,
   if he has a couple of drinks, he, that demon comes out of him
   and he wants to, he wants to suck a dick, you know, so he comes
   to see me. (African American, 39)

This passage illustrates two different aspects of the taboo script. First, it involved a married man who has sex with men when he is under the influence of alcohol. The participant's partner allows himself to act outside of the boundaries set by the normative heterosexual script, a cultural-level sexual script. Second, the participant himself was aware that his married partner would want to have sex with him once the partner has had some alcohol. Moreover, the partner performed oral sex on the participant, taking on the "passive" role. This further falls out of the heterosexual normative script in that the married "straight" partner played the receptive role. This particular participant claimed in his transcript to primarily play the insertive role in anal and oral sex, the top. His married partner's receptivity therefore reinforced the participant's sexual and social role.

Some participants in monogamous relationships discussed the role alcohol played in extra-relationship sexual encounters. Monogamy, like many other social constructs, is scripted by sets of rules and expectations of behavior. When these expectations are not met or when the rules are violated, there are often extenuating circumstances. For some participants, alcohol played the role of extenuating circumstance in their "infidelity scripts."

   I was so drunk, so, I had a good time. [Afterwards] I felt
   guilty, guilt, a lot of guilt. That's my first time I've been
   to bed with somebody else besides my partner. It still
   bothers me because just you know, I said, why did I do that. I
   know I did that because I was drunk and high. lf I would be sober,
   I would not do it. (Latino, 36)

   I was actually feeling a little guilty about my partner at home.
   And, that was part of it. I thought if I could not get so hot and
   heavy, it could assuage some of the guilt I was feeling.... By
   that time, it was like four, four-fifteen, wondering what my
   partner might be doing, if he was waiting up for me, if he was
   going to be able to tell that I had drinks. And, if I was going
   to smell like sex or just look like I had.... And, it's alcohol,
   always, always lowers my inhibitions. (Latino, 39)

The intrapsychic level of sexual scripts guided construction of taboo scripts related to the role participants ascribe to alcohol within their narratives about sexual encounters. In these narratives, participants performed sexual acts they feel are stigmatized, such as bottoming, or entertained negatively perceived thoughts, such as having unsafe sex. Engaging in these behaviors conflicts with the participants' roles in other social interactions. Their thoughts conflict with the social norms for what are considered acceptable and moral beliefs with regard to risk behavior. Therefore, taboo sexual scripts depend on the salience of cultural-level scripts that promote or discourage certain types of behavior.

DISCUSSION

As we mentioned previously, studies have sought to establish a correlation between drinking and unsafe sex using various quantitative methods. Recently, research found that sensation seeking was a possible mediator between alcohol consumption and sexual risk behavior (Kalichman et al., 2002). Even though these studies have highlighted the correlation between alcohol and sexual behavior, there is still a need to develop a qualitative understanding of how and why men use alcohol in sexual encounters.

This paper is a descriptive presentation of the role participants assigned to alcohol before or during sexual activity. Sexual behaviors were understood to be part of a structured activity, which could be represented on a timeline that began with preparation for going out and ended just after the sexual encounter. The present study highlights how participants consumed alcohol at different points along the activity timeline and ascribed varying roles to alcohol related to sexual activity. In addition, the various sexual scripts, depending on level and type, provided the context for partner selection, venue selection, choice to use or not use condoms, and other cognitive-behavioral factors (see Table 2 for a summary of sexual scripts.)

For some participants, alcohol was integrated into the interpersonal level of scripting, facilitating socialization or "setting the mood" for their interactions with partner(s). Some participants felt that alcohol was integral to the occurrence of sexual activity, while others believed that alcohol enabled them to engage in behaviors and thoughts they felt were taboo or stigmatized. Specifically, in situations that were considered taboo, alcohol seemed to enable an intrapsychic-level script that engaged both cultural scripts that proscribed certain behaviors and the participants' own desires. The time at which men drank, for how long, where, why, and to what extent was related to the role they assigned to alcohol. Moreover, the role alcohol played in the sexual activity structure impacted its role in sexual risk behavior.

Our findings echo the descriptions and motivations for behavior outlined in the cognitive escape model (McKirnan et al., 1996). This model emphasizes the dynamic relationship that alcohol has with contextual factors. Building on this model, as well as on recent work integrating alcohol expectancies and alcohol myopia models, we believe that alcohol myopia and cognitive impairment or disengagement are part of alcohol expectancies (George & Stoner, 2000; Morris & Alberry, 2001). These expectancies are one aspect of men's sexual scripts. Alcohol does not play a direct or dominant role in the sexual risk behaviors of the HIV-positive MSM in our sample. Rather, the intoxication is one aspect of a sexual script, which includes particular settings, partners, and sexual behaviors. The sexual scripts themselves are somewhat automatic and become more so under the influence of alcohol. Alcohol acts on these scripts by decreasing self-monitoring and increasing the reliance on default scripts, which are driven by environmental stimuli and situational cues. The diminishing of inhibitions and self-consciousness that alcohol brings about are themselves aspects of a culturally shared script regarding drinking and behavior that is fairly widespread as evidenced by the number of bars and by the ubiquity of alcohol in social situations. This raises the interesting point that cultural-level scripts include both proscriptions and the means to circumvent them within particular scenarios. In this instance, cultural-level scripts include ways of deflecting personal responsibility.

The default scripts that participants used could be seen as routine, spontaneous (alcohol enabled), or taboo. In their discussion of routine sexual behaviors, many participants discussed the fact that they drank in preparation for dates, before going out, or when they were waiting for a sex partner to arrive at the participant's home. In other words, at the intrapsychic level, alcohol influenced these participants' own emotional states before their sexual encounters. They experienced alcohol use as one of many steps leading to the sexual event (i.e., intrapsychic script). For some, it decreased social anxiety, shyness, or self-consciousness before meeting new people (i.e., interpersonal script). For others, it was a way to "set the mood" for a date. The interpersonal-level scripts dictated drinking as a means of bonding with friends or sexual partners.

In spontaneous sexual encounters, participants had been drinking and may not have anticipated having sex. These men engaged in sex if opportunities arose. Different categories of spontaneous sexual encounters emerged in the interviews. Some participants had sex with partners they would not have had sex with if they were sober. Others found themselves in situations that led them to engage in atypical or impulsive sexual behavior while under the influence of alcohol. Frequently, participants felt that alcohol led them to have sex prematurely with new partners. In general, the interpersonal level was extremely salient within participants' spontaneous sexual scripts.

The taboo script referred to participants who, while under the influence of alcohol, engaged in sexual behaviors and/or thoughts that they felt were socially stigmatized. These men often felt regret over their behaviors or qualified their narrative about engaging in these behaviors or thoughts by emphasizing the role played by alcohol. In the course of the interviews, participants described this as a recurring event. Due to the internalized social proscriptions associated with taboo sexual behaviors, these activities tend to be unplanned but remain a part of a regular pattern of sexual behavior. Scripts are one aspect within the sexual activity structure along with environmental and pharmacological effects. The taboo sexual encounter seems to be a case of alcohol acting to alter men's culturally driven primary sexual script (i.e., sexual tops may bottom, or HIV-positive men may contemplate infecting unknown or HIV-negative partners). In other words, participants use the expected pharmacological effects of alcohol to facilitate engagement in personally desired taboo sexual activities and thoughts.

Race and ethnicity were evenly distributed across two of the three basic sexual scripts (i.e., routine and spontaneous); however, no White participants expressed behaviors reflective of taboo sexual scripts. Under spontaneous scripts, it is interesting to note that both a White interviewee and an African American interviewee revealed elements of sexual compulsivity in their behavior. Recently, in a study of gay and bisexual men, Reece (2003) found that race and other demographic variables were not significantly related to sexual compulsivity. Thus, it should not be unusual to find racially and ethnically diverse gay and bisexual men reporting behaviors that may be related to sexual compulsivity. On the other hand, only African American and Latino participants reported taboo sexual scripts. Crawford, Allison, Zamboni, and Soto (2002) assert that higher risk of alcohol and substance use and other negative health risks among gay and bisexual men of color may be attributed to "heterosexist and race-based stress" (p. 179). Thus, the involvement of alcohol in taboo sexual scripts speaks to a need for these men to reduce this stress in order to express their personal desires. This may help explain why the participants in the present study were predominantly men of color.

By viewing the relationship between alcohol and unsafe sexual behaviors as one that develops differently across scenarios, it is possible to identify the specific roles alcohol may play in the sexual activities of HIV-positive MSM. Research is inconsistent on the direct impact of alcohol on unsafe sex behaviors. A qualitative investigation interrogates the possible connections suggested by quantitative research, making it possible to look at when HIV-seropositive MSM drink, how much, and for what reasons. This material is invaluable for researchers hoping to inform intervention practices and develop a clearer picture of when and how alcohol impacts unsafe sexual behaviors. This paper begins to address this issue by sketching how sexual activities are structured, what the driving scripts or scenarios are, what role alcohol plays, and what impact HIV-positive MSM with alcohol use problems say it has on their sexual behaviors.

Sketching the scripted roles ascribed to alcohol by alcohol-using HIV-positive MSM provides a clear picture of the dynamic relationship between alcohol and sexual behavior. Each of the scripts has its own sources of risk for unsafe sex. Interventions designed to address alcohol use and unsafe sex should be sensitive to the role which alcohol plays in the sexual scripts of target populations. Those who are primarily engaged in routine sexual scripts are not likely to be at risk for the same reasons as those who use alcohol when engaging in stigmatized sexual practices (i.e., taboo sexual script).

Within the routine sexual script, participants were at the least risk for engaging in unplanned unsafe sexual activity. At the intrapsychic level, they drank with the intention of "getting in the mood" or because it was part of "what you do" before having sex. These participants used or did not use condoms depending on their initial intentions. Risk came from beliefs about condoms, their relationship to their partners, or their beliefs related to HIV infection. These participants were much more in control of sexual situations than participants who engaged in other scripts.

Participants who engaged in spontaneous sexual scripts were much more likely to be at risk for unplanned unsafe sexual encounters. They drank and then engaged in sex, they believed, due to the effects of alcohol. Often these encounters were narrated as spontaneous in spite of being part of a regular pattern (i.e., scripted unplanned sexual encounters). These participants were not anticipating having sex and presumably had not predetermined the way in which a sexual encounter would unfold. They were at greater risk for not having a condom available, engaging in penetrative sex without intending to or being prepared to, or having sex in an unfamiliar environment with diminished self-monitoring and increased susceptibility to environmental cues. However, if these participants had well-established scripts for condom use and other protective sexual behaviors, alcohol would most likely have not impacted their sexual risk behavior.

For those participants who invoked the taboo sexual script, alcohol enabled them to engage in behaviors they may have found incompatible with their perception of themselves or their culturally informed value judgments (e.g., infidelity is wrong, thinking about intentionally transmitting HIV is immoral, bottoming is not compatible with masculinity). This cognitive dissonance resolved itself through alcohol myopia or cognitive impairment. These participants went into drinking knowing from experience that alcohol would impact their decision-making and self-monitoring and reduce inhibitions. However, they did not believe that they sought out these encounters. This script is in many ways another example of a spontaneous sexual script, except that the stigma attached to the behavior and/or thoughts makes it important to draw an analytic distinction. Moreover, due to the stigma, these participants distanced these sexual encounters from themselves: "I don't usually give up the ass." For these men, the self-distancing and lack of ownership may indicate a diminished sense of control or efficacy in these situations. This lack of ownership may also result in a lack of personal responsibility for the sexual encounter.

Even though none of the interviewees explicitly mentioned meeting their sexual partners online in their qualitative narratives, one should keep in mind that Internet chat rooms have become very popular as meeting places for gay and bisexual men, starting virtually and sometimes resulting in live meetings. Internet chatting was found to be part of the sexual script for a majority of men in a study conducted by Hospers, Harterink, van den Hoek, and Veenstra (2002). Thus, in future studies, it should not be surprising to find expectation of sex in the sexual scripts of men who meet online.

Further research is needed to better understand these sexual scripts, and to evaluate if similar scripts exist among HIV-negative MSM, MSM who use alcohol recreationally, and MSM of color of various sexual identities. Stokes, Vanable, and McKiernan (1996) state that ethnic group differences in same-gender behavior have been examined by few researchers. Considering that the majority of our sample was gay-identified and African American, it is imperative that future research, using more diverse samples of MSM, focus on the effects of race and ethnicity and sexual identity on sexual scripting among these diverse populations. Such research is especially important now considering how young MSM of color who do not disclose their sexual orientation are at higher risk for contracting HIV than their White counterparts (CDC, 2003). Understanding sexual scripts among members of these understudied populations may provide better guidance in planning and developing more effective, population-specific HIV prevention and treatment as well as drug and alcohol prevention and treatment programs.

Behavioral interventions designed to reduce the HIV sexual risk practices of HIV- seropositive MSM who abuse alcohol should consider the implications of sexual scripts and their role in sexual experiences. Cognitive or motivational interventions may be useful in helping HIV-positive MSM to understand their sexual scripts and the role that alcohol plays in scripting their sexual activities. Such approaches, which are designed to facilitate cognitive restructuring, amplify discrepancy, and increase self-monitoring, may benefit men through enabling script modifications.

Table 1. Characteristics of Study Participants (N = 48)

                                             n      %

Race-ethnicity
  African American                           29   60.4
  Latino/Hispanic                            10   20.8
  White                                       7   14.6
  Other                                       2    4.2
Sexual orientation
  Gay/homosexual                             37   77.1
  Bisexual                                    8   16.7
  Straight/heterosexual                       1    2.1
  Other/unsure                                2    4.2
Educational level
  Some high school                            6   12.5
  Graduated high school/GED                  14   29.2
  Some college                               18   37.5
  Bachelor's degree                           7   14.6
  Post-graduate degree                        3    6.3
Employment
  Full-time                                  10   20.8
  Part-time/odd jobs                          7   14.6
  Student                                     1    2.1
  Disabled                                   20   41.7
  Unemployed                                  3    6.3
  Institutionalized (jail, hospital)          2    4.2
Number of times treated for alcohol abuse
  0 times                                    21   43.8
  1-3 times                                  16   33.3
  4-9 times                                   6   12.5
  10-15 times                                 4    8.3
  16-30 times                                 1    2.1

Table 2. Summary of Sexual Scripts

Level/type                     Routine

Cultural             --Alcohol use as a ubiquitous
                       aspect of dating in American
                       society

Intrapsychic         --The emotional and cognitive
                       impact of alcohol (e.g., mood
                       setting, feeling sexier)
                     --Participants' internalized
                       cultural norms around
                       alcohol, dating, and sex

Interpersonal        --The effects of alcohol are part
                       of the scene with other partners;
                       it helps set the mood for them
                       and helps sexual partners feel
                       more affectionate and sexual
                       towards each other

Level/type                      Spontaneous

Cultural             --Certain behaviors more likely
                       to be condoned or at least
                       overlooked if people are under
                       the influence of alcohol
                     --Interactions under the influence
                       of environmental cues
                     --Within certain contexts,
                       sexual behavior as an accepted
                       possibility (e.g., sex clubs)

Intrapsychic         --Participants engaging in sexual
                       behavior they did not consciously
                       plan on (often part of a pattern
                       or scripted unplanned behavior)

Interpersonal        --MSM being more aggressive and
                       adventurous with potential partners
                       (e.g., approaching someone they
                       normally would not, exhibiting
                       behaviors in areas not designated
                       as a gay cruising area)

Level/type                      Taboo

Cultural             --Cultural stigmas around
                        particular types of sexual
                        activities (e.g., bottoming,
                        sex with men), identities (e.g.,
                        gay, lesbian, bisexual), or
                        thoughts (e.g., knowingly
                        infecting someone with the
                        HIV virus)

Intrapsychic         --Need to distance behavior from
                        internalized cultural stigma
                     --Means for deflecting
                        responsibility for psychologically
                        dissonant behaviors

Interpersonal        --Lowered standards for partners
                        ("not as choosy")
                     --Decreased sense of control
                     --Lowered standards for
                        partner selection
                     --Can act in a less inhibited
                        manner with their partners
                     --Preparation to engage in
                        "stigmatized" sexual acts
                        with potential sexual partners

REFERENCES

Adam, B. D., Sears, A., & Schellenberg, E. G. (2000). Accounting for unsafe sex: Interviews with men who have sex with men. The Journal of Sex Research, 37, 24-36.

Baigis, J., Francis, M. E., & Hoffman, M. (2003). Cost-effectiveness analysis of recruitment strategies in a community-based intervention study of HIV-infected persons. AIDS Care, 15, 717-728.

Blackard, J. T., Cohen D. E., & Mayer, K. H. (2002). Human immunodeficiency virus superinfection and recombination: Current state of knowledge and potential clinical consequences. Clinical Infectious Diseases, 34, 1108-1114.

Boulton, M., McLean, J., Fitzpatrick, R., & Hart, G. (1995). Gay men's accounts for unsafe sex. AIDS Care, 7, 619-630.

Boykin, K. (1996). One more river to cross: Black & gay in America. New York: Anchor Books.

Centers for Disease Control. (2000). HIV/AIDS among racial/ethnic minority men who have sex with men--United States, 1989-1998. Morbidity and Mortality Weekly Report, 52, 81-86.

Centers for Disease Control. (2003). HIV/STD risks in young men who have sex with men who do not disclose their sexual orientation--six U.S. cities, 1994-2000. Morbidity and Mortality Weekly Report, 49, 4-11.

Colfax, G. N., Buchbinder, S. P., Cornelisse, P. G. A., Vittinghoff, E., Mayer, K., & Celum, C. (2002). Sexual risk behaviors and implications for secondary HIV transmission during and after HIV seroconversion. AIDS, 16, 1529-1535.

Crawford, I., Allison, K., Zamboni, B., & Soto, T. (2002). The influence of dual-identity development on the psychosocial functioning of African-American gay and bisexual men. The Journal of Sex Research, 39, 179-189.

Crosby, G. M., Stall, R. D., Paul, J. P., Barrett, D. C., & Midanik, L. T. (1996). Condom use among gay/bisexual male substance abusers using the timeline follow-back method. Addictive Behaviors, 21, 249-257.

de Zwart, O., van Kerkhof, M. P. N., & Sandfort, T. G. M. (1998). Anal sex and gay men: The challenge of HIV and beyond. Journal of Psychology and Human Sexuality, 10, 89-102.

Diaz, R. M. (1998). Latino gay men and HIV: Culture, sexuality, and risk behavior New York: Routledge Press.

DiClemente R. J., Wingood, G. M., del Rio, C., & Crosby, R. A. (2002). Prevention interventions for HIV positive individuals. Sexually Transmitted Infections, 78, 393-395.

Dolezal, C., Meyer-Bahlburg, H. F. L., Remien, R. H., & Petkova, E. (1997). Substance use during sex and sensation seeking as predictors of sexual risk behavior among HIV+ and HIV- gay men. AIDS and Behavior, 1, 19-28.

Ekstrand, M. L., Stall, R. D., Paul, J. P., Osmond, D. H., & Coates, T. J. (1999). Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status. AIDS, 13, 1525-1533.

Fordham, G. (1995). Whiskey, women and song: Men, alcohol and AIDS in Northern Thailand. The Australian Journal of Anthropology, 6, 154-177.

Gagnon, J. H. (1977). Human sexualities. Glenview, IL: Scott Foresman.

Gagnon, J. H., & Simon, W. (1973). Sexual conduct: The social sources of human sexuality. Chicago: Aldine Publishing Co.

Gagnon, J. H., & Simon, W. (1987). The sexual scripting of oral genital contacts. Archives of Sexual Behavior, 16, 1-25.

George, W. H., & Stoner, S. A. (2000). Understanding acute alcohol effects on sexual behavior. Annual Review of Sex Research, 11, 92-123.

Gillmore, M. R., Morrison, D. M., Leigh, B. C., Hoppe, M. J., Gaylord, J., & Rainey, D. T. (2002). Does "high" = "high risk"? An event-based analysis of the relationship between substance use and unprotected anal sex among gay and bisexual men. AIDS and Behavior, 6, 361-370.

Hecht, F. M., Grant, R., Petropoulos, C., Dillon, B., Chesney, M. A., Tian, H., et al. (1998). Sexual transmission of HIV-1 variant resistant to multiple reverse-transcriptase and protease inhibitors. New England Journal of Medicine, 339, 307-343.

Kalichman, S. C. (2000). HIV transmission risk behaviors of men and women living with HIV-AIDS: Prevalence, predictors and emerging clinical interventions. Clinical Psychology: Science Practice, 7, 32-47.

Kalichman, S. C., Heckman, T., & Kelly, J. A. (1996). Sensation seeking as an explanation for the association between substance use and HIV-related sexual behavior. Archives of Sexual Behavior, 25, 141-154.

Kalichman, S. C., Kelly, J. A., & Rompa, D. (1997). Continued high-risk sex among HIV seropositive gay and bisexual men seeking HIV prevention services. Health Psychology, 16, 369-373.

Kalichman, S. C., Weinhardt, L., DiFonzo, K., Austin, J., & Luke, W. (2002). Sensation seeking and alcohol use as markers of sexual transmission risk behavior in HIV-positive men. Annals of Behavioral Medicine, 24, 229-235.

Leigh, B. C., & Stall, R. (1993). Substance use and risky sexual behavior for exposure to HIV. Issues in methodology, interpretation and prevention. American Psychologist, 48, 1035-1045.

Leonard, L., & Ross, M. W. (1997). The last sexual encounter: The contextualization of sexual risk behavior. International Journal of STD & AIDS, 8, 643-645.

Marks, G., Burris, S., & Peterman, T. A. (1999). Reducing sexual transmission of HIV from those who know they are infected: The need for personal and collective responsibility. AIDS, 13, 297-306.

McKirnan, D. J., Ostrow, D. G., & Hope, B. (1996). Sex, drugs and escape: A psychological model of HIV-risk sexual behaviours. AIDS Care, 8, 655-669.

Morris, A. B., & Albery, I. P. (2001). Alcohol consumption and HIV risk behaviors: Integrating the theories of alcohol myopia and outcome-expectancies. Addiction Research & Theory, 9, 73-86.

Muehlenhard, C. L., & Rodgers, C. S. (1998). Token resistance to sex: New perspectives on an old stereotype. Psychology of Women Quarterly, 22, 443-463.

Mutchler, M. G. (2000). Young gay men's stories in the states: Scripts, sex, and safety in the time of AIDS. Sexualities, 3, 31-54.

Parsons, J. T., & Halkitis, P. N. (2002). Sexual and drug using practices of HIV+ men who frequent commercial and public sex environments. AIDS Care, 14, 815-826.

Parsons, J. T., Halkitis, P. N., Wolitski, R. J., & Gomez, C. (2003). Correlates of sexual risk behaviors among HIV+ men who have sex with men. AIDS Education and Prevention, 15, 383-400.

Parsons, J. T., & Vicioso, K. J. (in press). Brief encounters: Public and commercial sex environments. In P. Halkitis, C. Gomez, & R. J. Wolitski (Eds.), Positive living: The sexual lives of HIV-seropositive gay and bisexual men. Washington, DC: American Psychological Association.

Purcell, D. W., Parsons, J. T., Halkitis, P. N., Mizuno, Y., & Woods, W. J. (2001). Substance use and sexual transmission risk behavior of HIV positive men who have sex with men. Journal of Substance Abuse, 13, 185-200.

Reece, M. (2003). Sexual compulsivity and HIV serostatus disclosure among men who have sex with men. Sexual Addiction & Compulsivity, 10, 1-11.

Reinert, D. E, & Allen, J. P. (2002). The Alcohol Use Disorders Identification Test (AUDIT): A review of recent research. Alcoholism: Clinical & Experimental Research, 26, 272-279.

Ross, M. W., Wodak, A., Miller, M. E., & Gold, J. (1993). Sexual partner choice in injecting drug users from a "critical incident" measure: Its implications for assessing risk for HIV spread. Sexological Review, l, 77-92.

Seal, D. W., Kelly, J. A., Bloom, E R., Stevenson, L. Y., Coley, B. I., & Broyles, L. A. (2000). HIV prevention with young men who have sex with men: What young men themselves say is needed. AIDS Care, 12, 5-26.

Sexton, R. L. (2001). Ritualized inebriation, violence, and social control in Cajun Mardi Gras. Anthropological Quarterly, 74, 28-39.

Simon, W., & Gagnon, J. H. (1986). Sexual scripts: Permanence and change. Archives of Sexual Behavior, 15, 97-120.

Simon, W., & Gagnon, J. H. (1999). Sexual scripts. In R. Parker & P. Aggleton (Eds.), Culture, society and sexuality: A Reader (pp. 29-38). London: UCL Press.

Steele, C. M, & Josephs, R. A. (1990). Alcohol myopia: Its prized and dangerous effects. American Psychologist, 45, 921-933.

Stokes, J. P., Vanable, P. A., & McKirnan, D. J. (1996). Ethnic differences in sexual behavior, condom use, and psychosocial variables among black and white men who have sex with men. The Journal of Sex Research, 33, 373-381.

Strauss, A., & Corbin, J. (1998). Basics of qualitative research (2nd ed.). London: Sage.

Watters, J. K., & Biernacki, P. (1989). Targeted sampling: Options and considerations for the study of hidden populations. Social Problems, 36, 416-430.

Weatherburn, P., Davies, P. M., Hickson, F. C. I., & Hunt, J. A. (1994). No connection between alcohol use and unsafe sex among gay and bisexual men. AIDS, 7, 115-119.

Wegesin, D. J., & Meyer-Bahlburg, H. F. L. (2000). Top/bottom self-label, anal sex practices, HIV risk, and gender role identity in gay men in New York City. Journal of Psychology and Human Sexuality, 12, 43-62.

Weinhardt, L. S., & Carey, M. P. (2000). Does alcohol lead to sexual risk behavior? Findings from event-level research. Annual Review of Sex Research, 11, 125-157.

Weis, D. L. (1998). Conclusion: The state of sexual theory. The Journal of Sex Research, 35, 100-114.

Whittier, D. K., & Simon, W. (200l). The fuzzy matrix of "my type" in intrapsychic sexual scripting. Sexualities, 4, 139-165.

Wolitski, R. J., Valdiserri, R. O., Denning, P. H., & Levine, W. C. (2001). Are we headed for a resurgence in the HIV epidemic among men who have sex with men? American Journal of Public Health, 91, 883-888.

Manuscript accepted September 16, 2003

zzz Positive Choices was supported by a grant from the National Institute for Alcohol Abuse and Alcoholism (R01 AA11808, Jeffrey T. Parsons, Principal Investigator). The authors acknowledge the contributions of other members of the Positive Choices team: Joseph P. Carbonari, Kirk yon Steinberg, David Bimbi, Aongus Burke, Thomas Borkowski, and Paris Mourgues. We also thank those who assisted with qualitative coding--Diane Tider, Mark Flores, Eric Martin, and Ellen Short--as well as those who assisted with the preparation of the manuscript: Jose Nanin, Jeremy Eggleston, and Whitney Missildine. We thank Kendall Bryant of the National Institute for Alcohol Abuse and Alcoholism for his input and support for t project.

Address correspondence to Jeffrey T. Parsons, Ph.D., Associate Professor, Department of Psychology, Hunter College of the City University of New York. 695 Park Avenue, New York, NY 10021; e-mail: jeffrey.parsons@ hunter.cuny.edu.

Jeffrey T. Parsons

Hunter College and the Graduate Center of the City University of New York

Kalil J. Vicioso and Joseph C. Punzalan

Graduate Center of the City University of New York

Perry N. Halkitis and Alexandra Kutnick

New York University

Mary M. Velasquez

University of Texas Medical School at Houston