Young unmarried men and women discuss men's role in contraceptive practice

Landry, David J

Focus groups with 76 sexually experienced young men and women living in the Denver area in 1993 explored the reasons unmarried men do or do not involve themselves in contraceptive practice. Motivation to use contraceptives is driven by a desire to prevent both pregnancy and sexually transmitted diseases (STDs), particularly AIDS. Despite dissatisfaction with the condom, both men and women report high rates of condom use. The method used, however, is dependent on the type of relationship involved, with condoms used more frequently in casual sexual relationships than in long-term relationships. Communication between partners about contraception is least likely to occur in casual relationships and in the early stages of a new sexual relationship. Despite awareness of the risks of STDs and pregnancy, both men and women report that they occasionally use no method at all or rely on a method other than condoms with casual partners. Most men and women in long-term relationships switch from condoms to other methods once they have had time to assess, often by unreliable means, their partner's risk status. (Family Planning Perspectives, 26:222-227, 1994)

At first intercourse, more than half of adolescent women rely on their partner to use a condom (47%) or withdrawal(8%) as a contraceptive method.(1) On a regular basis, more than one-fourth of all women using contraceptives rely on methods that require their partner's cooperation--15 use the condom, 12% vasectomy, 2% withdrawal and 2% use periodic abstinence.(2) Condoms are also used in conjunction with female-based contraceptive methods to prevent sexually transmitted diseases (STDs).(3) The recent rise in contraceptive use has been associated with an increase in condom use among men.(4)

Despite the critical part that men play in preventing pregnancy and STDs, their role in contraceptive decision-making is poorly understood.(5) To gain more insight into young, unmarried men's attitudes toward and involvement in contraception, The Alan Guttmacher Institute conducted a series of focus groups. Most of the groups were composed of men, but some were also conducted with women to obtain their perspective on male involvement. The focus groups addressed the following questions: How do young men define their involvement in contraception and disease prevention? How consistent are their attitudes about contraceptives with their behavior? To what extent do they discuss contraceptives with their sexual partners?

Methodology

A focus-group format was used to explore broadly how young men and women define men's role in contraception and why they do or do not use a method. Because focus groups are not representative of the general population and because participants may give socially desirable responses, the results of the study should be interpreted cautiously. Participants were drawn from an existing list of households in metropolitan Denver; at least one person in each household had expressed an interest in participating in a focus group. The list was compiled and maintained by Fieldwork Denver, a market research firm that also provided the facilities for conducting the focus groups.

Individuals in these households were eligible for the study if they had not participated in a focus group in the six months prior to selection; more than 75% had never participated in a focus group. Since the objective of the study was to learn about the dynamics of contraceptive use among young heterosexual men and women at high risk of being involved in an unintended pregnancy or of contracting an STD, married or separated respondents were excluded from the study. Potential participants--young men aged 16-29 and women aged 20-29--were asked to identify their race and ethnicity. To select heterosexual men and women who were sexually experienced, the interviewers also asked respondents if they had ever used a birth-control method, such as "pulling out," condoms or the pill with a partner of the opposite sex, or if they had ever had sex but did not use a method.

The focus-group sessions were held in October 1993 and averaged two hours in duration. As Table 1 shows, they ranged in size from four to eight participants.(Table 1 omitted) Nine groups were composed of a total of 53 men and three groups o a total of 23 women. The groups were divided into racial and ethnic categories of Hispanic, black non-Hispanic and white non-Hispanic, and the male participants were divided into age-groups of 16-17 years, 18-19 years and 20-29 years. For participants younger than 18 years, permission to participate in the study was obtained from the parents as well as the participants. Group moderators, who were experienced in handling reproductive and contraceptive issues, were matched with participants by gender and race or ethnicity.

All Hispanic participants were fluent in English and highly acculturated; most were born in the United States. Focus-group participants were not selected on the basis of their income or other indicators of social and economic status. Only four men among all group participants were unemployed and not in school; most were either students or were employed as blue-collar or service industry workers. One in five men were in college; among those in high school, about three-fourths were planning to go to college. Unlike the men, several of the women had professional occupations, but generally their educational and occupational levels were similar to the men.

Purposes of Contraception

To learn how young men and women define contraception and its purposes, moderators asked participants what comes to mind when they think of contraception. While many women in the focus groups thought that men's primary reason for contraceptive use was to avoid contracting an STD, most men said they were equally concerned about pregnancy. Many men were reluctant to rank their concerns about AIDS versus pregnancy. Most explained that avoiding both STDs and pregnancy are critical and should not be thought of independently,

"I would probably be just as scared if I got a girl pregnant, as I would if I got an STD."--Male, Age 19, Hispanic

A recent study of high school students in Miami found that when students ranked their concerns, almost half of the young men and more than half of the young women considered preventing pregnancy and preventing AIDS equally important.(6)

Preventing Pregnancy

The reasons men and women gave for using contraceptives to prevent pregnancy were similar. In most cases, they were concerned with their own well-being, not the well-being of their partner. The youngest men often cited fear of parental reaction; other men and women feared being "tied down," felt that they were not psychologically ready for parenthood or feared missing out on life opportunities.

"I would be more scared of the big responsibility. I would be thinking about how much I have people taking care of me at this point. I am not really taking care of myself."--Male, Age 16, Black

"I am concerned about pregnancy. I am more worried about my future. I don't want a child. I have to get my job."--Male, Age 16, White

The older men most often expressed concern about the financial commitment of supporting a child, but they usually did not mention the commitment to a partner that might be involved in having a child. The older women were also concerned about their inability to support a child financially and their uncertainty about the reliability of the father.

"I look at pregnancy, at this point in my life, as a threat, just because of the financial end of it. I am not personally financially ready for them. --Male, Age 28, Hispanic

Hispanic men, aged 18 or older, reported somewhat different concerns than did other participants. Some claimed that they only chose partners who were virgins or who had had few partners, thus decreasing their concerns about exposure to STDs. Several Hispanic men repeatedly expressed a belief that women, Hispanic women in particular, were very likely to try to trap them into a long-term relationship, or marriage, by becoming pregnant, thereby increasing their concerns about pregnancy. As a result of these two beliefs, most Hispanic men were more concerned about pregnancy than disease.

"My mom said that sometimes the girls are out there to trap me. They know that they aren't going any further. It's true. Sometimes those girls are out there trying to get a baby from someone. It's scary."--Male, Age 19, Hispanic

A theme repeated throughout the focus groups was the strong influence of family and friends on shaping the participants attitudes about pregnancy and STDs. Many younger men reported that knowing about the experiences of peers who were fathers or mothers was a major disincentive for them to become a father.

"All my cousins about my age are starting to have kids. Every time we have a family reunion, I hear about a new kid being born. It scares me when I see them. When I want them to go out, they can't because they're sitting there with their child."--Male, Age 18, Hispanic

In contrast, the older men and women mentioned that their friends who were mothers or fathers seemed to be doing fine, therefore they thought they, too, could handle parenthood.

"I see how a lot of my friends who are married and have kids become more comfortable with the fact. They can deal with it and move on. I could take the same direction."--Male, Age 28, White

The male participants were asked how they would react if their current partner told them she were pregnant. A majority of the white men said they would urge their partner to have an abortion, but most black and Hispanic men did not approve of abortion. Several men stated that if a man has sex he has to take responsibility for a pregnancy. Most men said they would want to be involved in the decision of what to do about a pregnancy; some said they would not accept their partner's decision to have an abortion.

"If my girlfriend told me she wanted an abortion it would have to be adoption or some type of compromise. Maybe she should give the baby over to me and I would take care of it myself. Abortion wouldn't even be in the picture."--Male, Age 16, Black

"If she gets pregnant, I'm ready to take the responsibility on. If I feel that I'm old enough and mature enough to play around with sex, then I ought to be able to take the responsibility of being a father to my baby. Hopefully, the girl will be in favor of that, too. But when it all comes down, it's really her decision. There is nothing that I can do about that."--Male, Age 19, Hispanic

"I would leave it up to her. I really would. I go both ways. It would be fine to have a child. But if it would mess her up and it is somewhat messing with my life, I would leave it up to her completely."--Male, Age 20, Black

Most men said they were aware of child support enforcement laws. However, they claimed that the issue of child support did not play a role in their decision to use a contraceptive. Many men, particularly black men, thought child support was unjust either because it was an intrusive system and they could deal with the issue voluntarily or, among those not allowed to see the child, because they were suspicious that the support was not being spent on their child. Nevertheless, some men did say that child support issues influenced their sexual behavior.

"There is always that question in my head: Just in case she became pregnant, can we afford it? Can she afford it if I am a bad father, if I just skip and don't take care of the baby?"--Male, Age 29, Black

"I do think of it before the act of sex. I put all of it, like the finances and taking care of it, under having a baby. I know all of the responsibilities and I don't want to have a baby because of that. I take all of that into account if I am going to do something with this person. I have to make sure that a pregnancy is prevented."--Male, Age 22, Black

Several black women commented that some black men do not care about pregnancy prevention. They thought most black men's primary concern was disease prevention. They also commented that the men who showed the least contraceptive responsibility were those who had children from several women, but who were not actively involved fathers.

Women generally believed that men should share the responsibility for contraception. They had a range of opinions on the extent to which men were actually responsible for contraception. Most women believed that men cared about contraception, although women in every group reported situations in which some men believed contraception was a women's responsibility. Several Hispanic women and white women thought that men were more concerned with preventing a pregnancy than STDs because they were ignorant or had a false sense of invincibility concerning STDs. Women had a general perception that men were more involved in discussing contraception and using condoms now than in the past. One Hispanic woman acknowledged increased male involvement, but felt that more men should take the initiative to discuss contraception.

Avoiding STDs

When asked to elaborate on the relative importance of using a contraceptive method for preventing pregnancy versus doing so to prevent STDs, many participants cited their fear of contracting an STD, especially AIDS, as a principal reason for their contraceptive use. The participants who had many partners were particularly concerned about AIDS. Most of the men mentioned condoms as the only method they knew of for disease prevention. Usually, the men viewed condoms as a means to avoid contracting an STD from a woman.

"Pregnancy can't kill you."--Male, Age 36, Black "I'm more concerned about getting a disease than I am getting a girl pregnant."-Male, Age 19, Hispanic

Several participants reported that they had experienced periods of high anxiety about whether or not they had been infected with the human immunodeficiency virus (HIV).

"I couldn't take thinking about AIDS anymore. It was on my mind 24 hours a day. Sometimes I felt like, 'Why am I going to college? I'm probably just going to find out I have AIDS in a couple of years and I have wasted all of this time.' It got to the point where I almost didn't want to start doing things. It just really got to me because I knew I was high risk. I just couldn't handle thinking about it. My mom talked me into getting tested."--Male, Age 19, White

Many, even the youngest participants, reported that they increased condom use because of knowledge about AIDS. Some participants felt that the information about AIDS alone had an impact on their behavior. Other participants, most of whom had received formal instruction about STDs in school, said they did not start to consider AIDS seriously or modify their behavior until they learned about people in their neighborhood, friends or relatives who had contracted HIV.

"As far as protecting myself from what is out there, it is like when I was younger I really didn't care. I went to sex ed. I saw slides of these people who had this and others who had that. At that time, I really didn't care. I thought that it couldn't happen to me. Then I began to see people that are messed up. They could have something permanent like AIDS or HIV. You start to really think about it."-Male, Age 16, Black

The older men and women reported that they had a more urgent need to use condoms now than in the past. They attributed this change in attitude to both their increased maturity in dealing with a relationship and an environment that they perceived as more dangerous as a result of the severity of AIDS, compared with other STDs. Some participants reported that they felt less at risk of contracting an STD because they choose partners who are virgins.

"The first time I had sex was in 1985. That is when AIDS was really just starting and there really wasn't much information about it. So I wasn't really all that worried about it. Compared from then until now, I use condoms more because of

AIDS."-Female, Age 27, Black Consistent with research that indicates knowledge about STDs other than AIDS is very limited,(7) most men were well informed about the transmission of HIV and how to avoid it, but their knowledge about other STDs was not very accurate. The relatively lower concern that men had about STDs other than AIDS is largely because most thought other STDs could be cured.

"I use condoms because of AIDS, pregnancy, and then the other STDs. I guess that if you get the other ones, you can be cured. With AIDS, your life is shortened."--Male, Age 18-19, Black

"I'm 24. When I was in high school, I didn't hear anything about AIDS. It was a VD and herpes thing. Back then I didn't use a condom. I didn't pay any attention. Then all of a sudden, this AIDS thing came on."--Male, Age 24, Black

Although both men and women were concerned about STDs, particularly AIDS, many thought they were at less risk than other people because they used condoms during most casual encounters, and they felt they were a good judge of their longterm partner's STD status. However, when presented with a scenario in which they were about to have unprotected sex with a partner infected with genital herpes, the participants overestimated their risk of contracting an STD. Many felt that it was virtually assured that they would become infected. The actual risk of a man contracting genital herpes from a single act of unprotected intercourse with an infected partner is estimated at 30%.(8)

Casual Relationships

The focus-group members' level of concern about pregnancy and AIDS, their use of contraceptives, and the type of contraceptive method they used often depended on the type of relationship in which they were involved. Relationship factors that influenced contraceptive use included their perception of their partner's STD status, seriousness of the relationship and its duration. Casual sexual relationships, often referred to as "one-night stands" by the focus-group participants, involve some of the highest risks of STD transmission or pregnancy because the individuals involved often do not care about their partner's well-being, communication about contraception is inadequate or nonexistent, and alcohol or drug use may cloud their judgment. Despite having knowledge that casual sex involves high STD risks, most of the older participants had had such relationships. Many of the more experienced men and women reported that as a result of recent information about AIDS, they were now less likely to engage in casual relationships. These results support other findings that knowledge about AIDS reduces risky behaviors, such as having multiple partners.(9)

Contraceptive Use Several men said they used contraceptives in casual relationships not to protect their partner but themselves from STDs, particularly AIDS.

"In most one-night-stand situations, you really don't care about the girl. You just care about yourself."--Male, Age 19, White

"The one-night stands--I would never go without a condom."--Male, Age 16, Black

"I wouldn't trust any girl nowadays. Nowadays, they go with other guys. You never know what they do, so you just use a condom all the time."--Male, Age 16, Hispanic

Although both the men and women thought it was important to use condoms in casual relationships, participants of all racial, ethnic and gender groups were generally dissatisfied with the method. Complaints about condoms included decreased physical satisfaction during intercourse, disruption caused by putting on a condom, and problems with condom breakage and slippage.

"I prefer not to have a condom on because of the pleasure and satisfaction."--Male, Age 18-19, Black

"I don't trust condoms. They bust."--Female, Age 29, Black

"Condoms are not too reliable. They break or aren't put on properly."--Female, Age 24, White

"A lot of the time they come off in the wrong place."--Female, Age 8, Hispanic

Despite these problems, many participants stated they received a great deal of emotional satisfaction from using condoms, which in part counteracted their negative attitudes. While many aspects of male involvement in reproductive health issues entail the avoidance of negative consequences,(10) some men reported that they benefited from using condoms.

"Having sex with a condom, there is a sigh of relief knowing that you have that 99% chance that you didn't catch anything and you didn't give her anything."--Male, Age 29, Black

"When I use them, I feel a lot more comfortable, more at ease."--Male, Age 28, Hispanic

Although most men and women professed that condom use was critical if they did not know their partner's HIV status, virtually all participants told stories of not using condoms when they knew they should have. The ambivalence regarding consistent use was frequently expressed. "Whenever you just meet a girl at a club who winds up coming back home with you, if it wasn't for AIDS, I wouldn't use a condom to just have sex with this person. There are times that I don't use one just because it isn't handy or something. AIDS has really made me be careful. I am very prudent about exactly what I do."--Male, Age 24, White

Many men and women said that although they generally avoided casual sex, alcohol and drug use made them more likely to have sex. Moreover, some participants said that when under the influence of alcohol or drugs, they were less likely to use a condom--or any other contraceptive method. Several of the participants remarked that the day after, when their judgment was better, they had deep regrets about engaging in casual sex, particularly if they had not used condoms.

"I was drunk and I didn't worry about using condoms at the time. But the next day, I was paranoid. 'Oh no. What did I do?' I was thinking about it all day."--Male, Age 18, White

"In my case the only thing that makes me slip is alcohol. And it doesn't happen every time. But the times that I have, I have been intoxicated."--Female, Age 23, Black

Communication with Partner

Male participants said they rarely discussed contraceptive use with a casual partner. Most men reported that shortly before intercourse, they either produced a condom or asked their partner if she was using a method. The participants did not call this discourse a "discussion" about contraception. Although most of the conversation centered around ensuring that a condom would be used, some men said they were not so concerned about their partner's STD status, but simply wanted to make sure some method was used.

"In one night stands, a discussion never comes up. Basically you just have to think for yourself. If it doesn't come up, it is you saving yourself."--Male, Age 17, White

"It's usually right before. I ask them if they are on the pill. I will ask them that if I can't find a condom."--Male, Age 18-19, Hispanic

"Basically I just put it on. I don't even talk about it."--Male, Age 17, Hispanic

"When I am with someone who I know, I can talk about it. But just some stranger, I won't really talk about it. I'll just do it."--Male, Age 23, White

Many of the younger men and those engaging in casual relationships said they were uncomfortable discussing contraception. They reported that they did not trust the motives of women who initiate such discussions; others relied on their partner's female method and did not discuss it.

"I talked about contraception just once. They don't really want to talk about it because they feel uncomfortable about it." --Male, Age 23, Hispanic

"I avoid talking about contraception. When they start talking about it, it seems like they are planning it or something. Maybe they are already pregnant and they are just trying to put the blame on you or something."--Male, Age 18, Black

"It feels weird talking about it. I wouldn't want to sit down and talk to her about it."-Male, Age 16, Hispanic

Discussion of contraception was also restrained among the younger participants because of a fear of rumors, particularly in a high school setting.

"She is just getting nosy. Some girls just want to know who you slept with and what you did with them so that they can talk about it."--Male, Age 16, Black

Focus-group participants of all racial, ethnic, gender and age-groups reported that many women demanded condom use, and in almost every case the men complied. Most of the men said that women initiated conversations about contraception. They added that the woman's initiative often determined whether or not condoms or any other contraceptive was used because some men had condoms available but would use them only if they had to. Some women said they would withhold sex unless a condom was used. Many women felt that men do not care about contraception because they only care about sex, not pregnancy or STDs; therefore, they felt they must take the responsibility of bringing up the issue of contraception.

"If they want me to wear it, I will. There aren't many times that I don't wear it. No matter what they say. I usually wear a condom."--Male, Age 18, Black

"I usually don't have a condom, but I don't argue with them. But if they are at the point where they are not going to have sex if you don't have a condom on, I try to talk them out of it. Or I will just fake putting one on and you will go [makes noise]. That has happened once. The girl was really pissed and I kind of felt bad."--Male, Age 19, White

Research has shown that younger women who are not sexually experienced are more likely to be unprepared to discuss contraception or have contraceptives available,(11) and men and women in the focus groups reported that younger women were the least likely to take the initiative to discuss contraception.

"In high school, a lot of the girls didn't care. They didn't ask because they don't know what is going on. Now I meet a lot of girls a couple years older than me. They are a lot more conscious about condoms. They are more wise and ask about it."--Male, Age 19, White

One study found that less-acculturated Hispanic men had negative attitudes about women who have condoms available for their partners.(12) In contrast, most men in the Denver focus groups had positive attitudes about women who had condoms available.

"I think that she has a lot of respect. She is looking out for herself and looking out for you."--Male, Age 18-19, Black

"I would admire her for taking the responsibility of having a condom...; I would respect her much more."--Male, Age 23, Hispanic

Although discussion about contraception before intercourse often promoted method use, both men and women said they felt awkward bringing up the subject of contraception early in a relationship. As other research has found,(13) many participants in the focus groups said they did not feel comfortable talking about contraception until several weeks had passed from the time they first had sex. They often felt uncomfortable bringing up sensitive topics, such as number of previous partners, and pregnancy and STD history.

"I have always talked about it if I were going out with a girl for about three or four weeks. I think that eventually when you are going out with somebody and having sex with them for three or four weeks, you bring it out. At the beginning stages of a relationship, I think that it is a little awkward to talk about."--Male, Age 24, White

"I was living with my girlfriend for a while. We'd go at it all the time. After a while, I felt like I didn't want to get her pregnant. We both kind of brought it up at the same time."--Male, Age 17, Hispanic

Often the impetus for initiating a discussion is fear of a possible pregnancy resulting from nonuse of a contraceptive method during a previous act of intercourse.

"The last girl I was with, we did it on the same day. We didn't talk about that. I didn't know she wasn't on anything. She knew I didn't have a condom. After a couple of weeks went on, we talked about it because I was scared she was pregnant. After that I started using condoms."--Male, Age 24, Hispanic

"She might say, 'Last night we were close.' I may have not had a condom. She might say, 'You know that I don't want to get pregnant.' The conversation is usually something like that. I will say, 'We have to be careful because I don't plan on having no kids either'."--Male, Age 18-19, Black

Although not common among the focus-group participants, some men said they normally had extensive conversations about sex and contraception with their partner. These participants tended to be older, avoided casual sexual encounters, always used a contraceptive method, sought relationships that involved an emotional element as well as a sexual one and said they cared about the well-being of their partner. They often initiated discussion several days or weeks before they had sex. One female participant stated that her partner had initiated an in-depth conversation about contraception before they had sex.

"These days, I'm able to speak more freely and openly about sex as compared to when I was younger. When I was younger, the talk that I had about sex really objectified women. So, these days, you must know more about taking responsibility, about sexual variety, experiences. It is no longer taboo to talk about it these days for me."--Male, Age 28, Hispanic

"My boyfriend was concerned about contraception. We talked about it even before we ever had sex. He asked me if I was on any protection and I told him, 'No.' It was a big issue and concern to him."--Female, Age 28, White

Some teenage males said they had received instruction in sex education class about discussing sex with a woman. In a few instances, they also said they had had extensive conversations with women about contraception.

"In my class, we talked about the communications between partners. They make it real clear that is very important. With a lack of communication, there is really nothing there. When you have sex without the communication, it is really not worth it. You will look at the girl differently. She might not look as good and stuff."--Male, Age 17, White

Long-Term Relationships

Male involvement in contraception was markedly different in long-term relationships. These types of relationships were often characterized by more involved discussions about contraception, couple STD testing and method switching. Some men and women continued using condoms in long-term relationships, for a variety of reasons: because they were not monogamous or at least one partner did not trust that the other was monogamous; because they used dual methods, including the condom, to lower their risk of an unintended pregnancy; or because some men did not trust their partner's ability to use female methods consistently.

"I am not thinking that he is going to go off and go stray or anything. But, condoms and pills just go together. It is like brushing your teeth."--Female, Age 27, Black

"Most females I talk to might skip a day. For that day they skipped, they might start taking extra. Just because a girl is on the pill, it might make a difference, but it mostly doesn't. I don't know if they are being responsible with taking it."--Male, Age 18-19, Black

Most participants in long-term relationships had switched from one contraceptive method to another. In long-term relationships, method switching often involved changing from condoms to a female method or from condoms and a female method to a female method only. However, some men and women remarked that after developing a stronger relationship with their partner, they used both condoms and a female method to ensure preventing pregnancy.

The participants gave two main reasons for switching from condoms to another method: dislike of condoms and reduced fear of STDs within the context of the relationship. The decrease in fear was usually the result of trusting their partner, rather than engaging in conversations about previous risk behaviors or being tested for STDs. However, some participants said they had discussed their sexual history with their partners, sometimes at great length, and would switch from condoms to another method only if they were convinced that their partner was risk-free and would remain monogamous.

"In a long-term relationship, at the beginning yes, I would use a condom. But once the trust is built up and we've found out about the sexual history, then I would stop using condoms, but use other forms of birth control."-Male, Age 27, Hispanic

In several cases, participants went beyond relying on trust or detailed conversations about their partner's sexual history. They did not feel it was safe to switch to a female method unless both partners were tested for HIV.

"If I get a relationship going, we both go get AIDS tests. If it is going to be an ongoing thing, every six months, we are both going. Just meeting somebody or even dating them for a month or two, you just can't say, 'Well, I'm going to take off my jimmy because I've known this girl for a month or two'."--Male, Age 29, Black

"It was something that I wanted to know for myself. You don't want your past to come back and haunt you. I went by myself first. Then the next time I went, I went with my lady. I don't want to go around spreading anything."--Male, Age 18-19, Black

Among participants who had switched from using condoms or dual methods to using a female method only, most men reported that their involvement in contraception was minimal, and that they rarely continued discussing the topic with their partner. Several men in long-term relationships could not even recall which method their partner was currently using. Although most participants who had switched to a female method said the decision was made jointly, both men and women had difficulty suggesting how men could increase their involvement in these situations. One woman suggested that her partner should share in the cost of her pills. Despite limited involvement by most men whose partner was using a female method, some said they continued to be involved in contraception, and a few went to great lengths to make sure both partners were responsible.

"I check her pills. It has the days of the week labeled on it. It also has a date. I always check them. This is just me. Just to make sure she is doing her part. We made that agreement. I want to make sure that she is holding up to her part. She chose to be the responsible one on that. I have to buy the condoms and wear them."--Male, Age 18-19, Black

Discussion

In general, differences in contraceptive practice by the focus group participants' racial and ethnic background were minimal; these minor differences may reflect the relatively homogeneous social and economic background of the participants and the fact that only highly acculturated Hispanics participated. More apparent indicators of a man's contraceptive use were a strong future orientation, concern about his partner and nonuse of alcohol or drugs. before having sex.

While male participants said that awareness of AIDS had increased their involvement in contraception, they were also highly motivated to use a contraceptive to avoid pregnancy. In fact, many men in long-term relationships said pregnancy prevention was the only reason they practiced contraception. Younger men feared a pregnancy would negatively alter their life-style and force them to lower their educational and employment aspirations; older men were primarily concerned about the high cost of raising a child. Further research is needed to ascertain if educational programs, counseling and media messages that address concerns about unwanted pregnancy can increase contraceptive use.

Focus-group participants stated that information about AIDS affected their own behavior in terms of reducing the number of their casual sexual partners and increasing their use of condoms until they had determined their partner was STD free. While knowledge appears to have improved these groups' contraceptive efficacy, increasing specific types of knowledge and skills may help to further reduce STDs and unintended pregnancies.

One of the most fundamental areas where there was a lack of knowledge centered on STDs. While most participants could identify at least one incurable STD, many improperly identified several as being curable. If knowledge was improved about the general prevalence of STDs and the number and type of incurable STDs, the perception of risk among young men and women may be raised to the extent that they would be more motivated to use condoms. In general more research is needed on how to effectively teach people how they can more accurately assess their own risk behavior.(14) These focus groups show that teenagers and young adults need repeated, age-appropriate instruction about STDs, and older adults need to know where to find information about STDs when they are no longer in school.

One of the most unreliable practices that focus-group participants used was their own instincts about their partner's STD status. Most participants relied upon "instinctive" criteria in making the decision to switch from condoms to another form of birth control. Only a minority of participants went to a clinic or doctor's office with their partner for joint risk assessment, counseling and testing. Teenagers and young adults need more information about how to determine their own risk status, as well as that of their partners. They should be urged to always use at least condoms until they and their partner consult with a reproductive health professional.

Despite the fact that most participants were well informed about the risks of AIDS and were personally motivated to prevent STDs and pregnancy, almost every person had accounts about how they took risks having sex with no condom and with no contraceptive at all. Knowledge and intentions are not always consistent with actions, particularly when it involves sexual behavior.

Practitioners need to tailor the message about consistent condom use to confront attitudes and situations that make condom use unlikely to occur. For instance, a majority of both male and female participants disliked condoms, often because of slippage and breakage. Increased training in the proper use of condoms could reduce slippage and breakage, thereby reducing dissatisfaction and increasing use.

A small minority of male focus-group participants expressed little concern about the well-being of their female partners. This group of men was the most likely to use no contraceptive method. Yet most men and women--even those who did not particularly care about the welfare of their partner and engaged in risky sexual behavior--had moments of marked anxiety over their fear of contracting an STD or being involved in a pregnancy. This anxiety did not occur until after unprotected sex. Often alcohol or drugs were involved in the nonuse of condoms and contraceptives.

These high risk situations could be reduced if both young men and women received early and adequate training and skills that involve role playing, learning to delay sex, and negotiating sex and contraceptive use. Young adults need to feel at least as comfortable with talking about sex as they are with having sex. Educational programs designed to delay the onset of intercourse and equip young adults with the communication skills necessary to accept or reject sex on their own terms have been shown to promote communication between partners and increase method use.(15) It should be made clear that individuals are not ready to have sex until they have developed the type of relationship in which they can talk freely and in detail with their partner about sex and contraceptive use.

References

1. J. D. Forrest and S. Singh, "The Sexual and Reproductive Behavior of American Women, 1982-1988," Family Planning Perspectives, 22:206-214, 1990.

2. W. D. Mosher, "Contraceptive Practice in the United States, 1982-1988," Family Planning Perspectives, 22:198-205, 1990 Table 3.

3. W. Cates, Jr., and K. M. Stone, "Family Planning, Sexually Transmitted Diseases and Contraceptive Choice: A Literature Update--Part I," Family Planning Perspectives, 24:75-84, 1992; and --, "Family Planning, Sexually Transmitted Diseases and Contraceptive Choice: A Literature Update--Part II," Family Planning Perspectives, 24:122-128, 1992.

4. M. D. Mosher and J. W. McNally, "Contraceptive Use at First Premarital Intercourse: United States, 1966-1988," Family Planning Perspectives, 23:108-116, 1991.

5. S. Edwards, "The Role of Men in Contraceptive Decision-Making: Current Knowledge and Future Implications." Family Planning Perspectives, 26:77-82, 1994.

6. L. M. Langer, R. S. Zimmerman and J. A. Katz. "Which Is More Important to High School Students: Preventing Pregnancy or Preventing AIDS?" Family Planning Perspectives, 26:154-159, 1994.

7. EDK Associates, Women and Sexually Transmitted Diseases: The Dangers of Denial, The American Medical Women's Association, Washington, D. C., 1994, pp. 10-11.

8. S. K. Harlap, K. Kost, and J. D. Forrest, Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States, Alan Guttmacher Institute, New York, 1991, Figure 6.4.

9. D. Holtzman et al., "Changes in HIV-Related Information Sources, Instruction, Knowledge, and Behaviors Among U.S. High School Students, 1989 and 1990," American Journal of Public Health, 84:388-393, 1994.

10. S. Edwards, 1994, op. cit. (see reference 5); and G. D. Zimet et al., "Relationship of AIDS-Related Attitudes to Sexual Behavior Changes in Adolescents," Journal of Adolescent Health, 13:493-498, 1992.

11. G. Cvetkovich and B. Grote, "Psychosocial Maturity and Teenage Contraceptive Use: An Investigation of Decision-Making and Communication Skills," Population and Environment, 4:211-226, 1981.

12. K. A. Forrest et al., "Exploring Norms and Beliefs Related to AIDS Prevention Among California Hispanic Men in the United States," Family Planning Perspectives, 25:111-117, 1993.

13. D. Polit-O'Hara and J. R. Kahn, "Communication and Contraceptive Practices in Adolescent Couples," Adolescence, 20:33-43, 1985.

14. R. J. DiClemente et al., "Comparison of AIDS Knowledge and HIV-Related Sexual Risk Behaviors Among Adolescents in Low and High AIDS Prevalence Communities," Journal of Adolescent Health, 14:231-236, 1993.

15. D. Kirby et al., "School-Based Programs to Reduce Sexual Risk Behaviors: A Review of Effectiveness," Public Health Reports, 109:339-360, 1994.

David J. Landry is senior research associate and Theresa M. Camelo is senior research assistant at The Alan Guttmacher Institute (AGI). This project was supported by a grant from the Henry J. Kaiser Foundation. The authors wish to thank AGI colleagues Jacqueline Darroch Forrest, Cory Richards, Daniel Daley and Lisa Kaeser for helpful comments. Thanks also go to Amanda Houston Hamilton, William Marsiglio, Paul Warner and Gloria Williams for their help with the discussion guide, moderation and debriefing sessions, and to Anne McIntyre and staff at Fieldwork Denver.

Copyright The Alan Guttmacher Institute Sep 1994
Provided by ProQuest Information and Learning Company. All rights Reserved