Objectives A core construct targeted by behavioural interventions is the perception that one is at risk for acquiring a sexually transmitted disease (STD). The objective of this analysis was to examine the role of intimacy on perceptions of risk for an STD (PRSTD) and condom use within late adolescent females' main relationships.
Methods A clinical sample of African–American women aged 14–19 years at enrolment were followed prospectively for 3 years. At each semiannual interview, participants reported their partner-specific PRSTD, feelings of intimacy, perceptions of partner's concurrency and condom use at last sex for each of their main sex partners.
Results A total of 285 individuals reported 724 main relationships. Using generalised estimating equations, intimacy was negatively associated with risk perception, after adjusting for perceptions of partner concurrency (OR: 0.68; 95% CI 0.60 to 0.76). PRSTD was no longer associated with condom use after adjusting for intimacy (OR: 1.30; 95% CI 0.83 to 2.02.
Conclusions Intimacy was found to be associated with risk perception and condom use within adolescent main relationships. Adolescents may not view their intimate partners as sources of infection. The success of individual-level STD prevention efforts, such as condom promotion, might be limited as condoms may be in conflict with adolescents' expectations about intimate relationships.
- cohort studies
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Tremendous age disparities in the incidence of sexually transmitted diseases (STDs) exist in the USA. While young people aged 15–24 years represent only 25% of the sexually experienced population, they acquire nearly half of all new STD.1 Young African–American women in particular are more than six times more likely to become infected with an STD compared with their white peers.1 Public policy continues to emphasise the need for effective developmentally appropriate interventions to reduce prevalence of STD among US youth that may be paired with effective coital-dependent behaviours including condom use and pre-exposure prophylaxis (PreP).
A core construct targeted by behavioural interventions is the perception that one is at risk for acquiring an STD.2 Furthermore, investigators have shown that perception of risk and its relevance to behavioural interventions depends on the type of sex partner.3 Adolescents who perceived themselves to be at risk for an STD from a main sex partner are more likely to use a condom with a main sex partner. Perceptions of risk do not predict condom use with a casual sex partner.4 Casual sex partner-specific condom use and perceptions of risk are consistently high among youth.5 ,6 In contrast, main partner-specific condom use and perception of risk are, on average, lower and vary from youth to youth.7–9 As such, main partner-specific condom use and perceptions of risk may be a prime target for intervention.
Little is known about why there might be variation in perceptions of risk for main sex partners and thus variation in condom use. The term main partnership is considered to represent relationships marked by feelings of intimacy, or emotional connectedness, which distinguish it from other partner types.10–12 Level of emotional as opposed to sexual involvement has been found to define types of adolescent relationships.13 Studies that have examined relationship qualities have found adolescents' higher feelings of trust and intimacy was associated with lower levels of condom use in their relationships.14 ,15 Variation in risk perception and condom use may be attributable to differing levels of intimacy within or between main sex partner relationships. The thought being that there is an inverse correlation between perception of risk and intimacy. For example, when intimacy is low at the start of a relationship, perceived risk for sexually transmitted diseases (PRSTD) is high and condom use is high, but with time, there is increasing intimacy and decreased PRSTD and condom use.11 ,12
One potentially important confounder of the association between intimacy and perceptions of risk is perceived partner concurrency. Adolescents who believe that their main partner has other sex partners are more likely to perceive themselves to be at risk for an STD from that partner.16 Perceiving that their partner has other sex partners may also lead to lower levels of intimacy. As we try to develop the next generation of behavioural interventions for youth, it will be essential to tease this relationship apart as strategies to address intimacy differ from strategies to influence partner concurrency.
The objective of this analysis was to examine the role of intimacy on perceptions of risk for a sexually transmitted disease and condom use within the relationships of adolescent and young adult women. Specifically, we aimed to test our hypotheses that (1) partner-specific feelings of intimacy will be associated with perceptions of risk among young women in main sex partner relationships after adjusting for perceived partner concurrency and (2) perceptions of risk, after adjusting for intimacy, will be associated with condom use among the same women.
We recruited adolescent and young adult women, aged 14–19 years, from two urban health clinics, a hospital-based adolescent medicine clinic and a public STD clinic, in Baltimore, Maryland, and followed them as a prospective cohort for 3 years. Between July 2000 and September 2002, 289 African–American adolescent women were enrolled in the Perceived Risk for Sexually Transmitted Diseases (PRSTD) study. Eligibility criteria included vaginal or anal intercourse with an opposite sex partner in the preceding 6 months, English speaking and residence in the Baltimore metropolitan area. Seventy-four per cent of eligible women agreed to participate. Participants were interviewed at baseline and at 6-month intervals for 3 years (a total of seven interviews). Trained research assistants, all of whom were African–American women, conducted the baseline and semiannual interviews face to face. The interviews were conducted in a private office in the clinic and lasted approximately 1 h. Participants received monetary compensation for completing each interview. All participants provided written informed consent; parental consent was not required. The Johns Hopkins University Institutional Review Board approved the study protocol.
For this analysis, our primary variables of interest were participant-reported measures of perceived partner concurrency, PRSTD, feelings of intimacy and condom use, which were assessed for each main sex partner at each semiannual visit.
At each interview, adolescent women were asked to list, using first name only, all of their sexual partners in the 3 months preceding the interview. Participants were asked to classify each sexual partner as a main or a casual partner. We defined a main sex partner as “someone you have sex with and you consider to be the person you are serious about.” We defined a casual partner as “someone you've had sex with only once, or a few times or you have sex with on an on-going, casual basis. The important thing is that this person is not a main partner to you.” The current analysis was limited to the sex partners that the participants classified as main partners.
Perceived partner concurrency
For each partner, participants were asked “To the best of your knowledge, did he ever have other sex partners while you two were having a sexual relationship?” with a response option of yes, no or don't know.
Perceived risk for a sexually transmitted disease
For each partner, participants were asked “How likely are you to get an STD from this partner if you do not use a condom with him?” using a five-item Likert scale. Possible responses were: not at all, not very, somewhat, very and extremely. Values range from 1 to 5 going from low to high PRSTD.
Three questions were used to assess feelings of intimacy for a partner. Participants were asked, “How close do you feel to this partner?”, “Do you trust this partner?” and “Do you love this partner?” using a four-item Likert scale. Possible responses were: not at all, not very, somewhat and very, which we quantified on an ordinal scale represented from 1 (low) to 4 (high) and totalled to provide a summary score for each partner. The intimacy score could range from 3 to 12, going from low to high intimacy, and had an α of 0.72.
For each partner, participants were asked whether or not a condom was used the last time they had sex with this partner.
For purposes of interpretation, we transformed our continuous but not normally distributed dependent variable into a categorical variable. PRSTD was treated as binary comparing those who thought they were extremely likely and very likely to acquire an STD from their partner to those who responded they were somewhat, not very or not at all likely to acquire an STD from their partner. Condom at last sex was a binary-dependent variable. Intimacy was modelled as a continuous independent variable. Perceptions of partner concurrency was a binary-independent variable; don't know responses (15% of responses) were combined with yes responses in the analysis.
Adjusted models included participant's chronological age to control for individual development and mother's education coded as less than or equal to a high school diploma versus more education to control for socioeconomic status. We did not adjust for condom attitudes as has been done in previous analyses examining the relationship between perception of risk and condom use because while condom attitudes have been found to be significantly associated with PRSTD, adjusting for condom attitudes did not changes the relationship between PRSTD and condom use.4
Each main relationship was included in the analysis only once. In instances where the partner was mentioned at two different interviews, we used data from the most recent interview. As the outcomes for both models were binary, generalised estimating equations was used to estimate the ORs, controlling for the correlation between multiple relationships within an individual.17 All analyses were conducted using SAS software, V.9.2.18
Seventy-one per cent of the cohort was retained over 3 years. Among the participants who completed the 6-month interview, the retention rate at 36 months was 85%. There were no differences in age or risk behaviour at baseline between those completing the study and those lost to follow-up.
The analytical sample consisted of 724 relationships within 285 African–American women. Participants contributed a mean of 2.5 (SD=1.3) relationships to the analysis, ranging from 1 to 7. Table 1 presents baseline characteristics for the 285 women who contributed a main partnership to this analysis. Participants were 17.1 years old on average at enrolment. The mean age of the participants at the interview used in the analysis was 19.2 years (1.8). The mean age at first sexual intercourse (vaginal or anal) was 14.2 years. Sixty-seven per cent of participants reported that their mother had less than or equal to a high school education. The median number of lifetime sexual partners was 5 and 63.7% of the sample reported ever having an STD at baseline. The median length of relationship was 15.5 months, the mean (SD) length of relationship was 25 (31.9) months long and a condom was used at last sex in 46% of relationships. There were low rates of missing data on key measures, ranging from 0.6% to 1.8% for condom use, PRSTD, intimacy and perceptions of partner concurrency.
Overall participants reported low perception of risk for acquiring an STD and high levels of intimacy in their relationships. Among 724 relationships, the overall mean (SD) for PRSTD was 2.1 (1.2) out of a range of 1–5 and for intimacy was 10.3 (1.8) out of a range of 3–12. The per cent who perceived partner concurrency was 43.9% and the per cent of condom use at last sex was 42.1%.
Intimacy and PRSTD
Table 2 presents results from models generated using generalised estimating equations to examine the association between partner-specific feelings of intimacy and PRSTD, adjusting for perceived partner concurrency. The bivariable associations indicate a significant inverse association between intimacy and PRSTD (OR: 0.66, 95% CI 0.59 to 0.74). In relationships in which individuals reported higher intimacy, those individuals were less likely to perceive themselves at risk for acquiring an STD from their partner. Perceiving partner concurrency was positively associated with partner-specific PRSTD (OR: 1.68; 95% CI 1.10 to 2.57). In relationships in which individuals perceived their partner to have other sex partners (concurrency), those individuals perceived themselves to be at greater risk of acquiring an STD from that partner. After adjusting for intimacy, perceived partner concurrency was no longer statistically significantly associated with PRSTD (OR: 1.24; 95% CI 0.81 to 1.90); however, the relationship between intimacy and PRSTD is virtually unchanged (OR: 0.67; 95% CI: 0.60 to 0.76). Findings are similar in the fully adjusted model after adjusting for participant's age at interview and mother's education.
PRSTD and intimacy and condom use
Table 3 presents results examining the association between partner-specific PRSTD and condom use, adjusting for feelings of intimacy. The bivariable associations indicate a significant positive association between PRSTD and condom use (OR: 1.57; 95% CI 1.01 to 2.46). In relationships in which individuals reported perceiving themselves to be at high risk of acquiring an STD from their partner, those individuals were more likely to use a condom with that partner. There was a significant inverse association between intimacy and condom use (OR: 0.82, 95% CI 0.75 to 0.90). In relationships in which individuals reported higher intimacy, those individuals were less likely to use a condom with their partner. After adjusting for intimacy, PRSTD was no longer associated with condom use (OR: 1.17; 95% CI 0.71 to 1.94); however, the relationship between intimacy and condom use was virtually unchanged (OR: 0.83, 95% CI 0.75 to 0.91). Findings are similar in the fully adjusted model, which included participant's age at interview and mother's education.
High intimacy main relationships
Given the importance of intimacy in our findings, we conducted a post hoc analysis to explore what constitutes a high-intimacy sexual relationship. Table 4 presents results of bivariable analyses, examining the odds of feeling high intimacy for a main partner for several partner and relationship characteristics. Factors positively associated with high intimacy included an age difference greater than 3 years, higher sexual frequency, longer relationship duration, exchange of money or gifts, the sexual partner's participation in a gang, knowledge of the relationship by others and cohabitation. Whereas drug dealing by the main partner, perceived concurrency, exchange of drugs or money for sex and verbal abuse were associated with lower reported intimacy.
Findings from this study illustrate the important role feelings of intimacy play for adolescent and young adult women when navigating STD risk in the context of their romantic relationships and may have profound impact on interventions focused on condom use or other coital-dependent behaviours such as PreP. Our data provide evidence to support our hypothesis that feelings of intimacy are associated with PRSTD and that previous findings of an association between PRSTD and condom use might be confounded by intimacy.
The formation of romantic relationships is a key developmental task of late adolescents.19 As adolescents enter increasingly intimate relationships, perceiving STD risk is incompatible with traditional views of main relationships.15 Intimacy reflects a core dimension that characterises individuals' cognitions about ideal romantic relationships.20 ,21 Risk perception should thus be viewed within the context of more specific relationship cognitions, including individuals' assumptions about how relationships work (eg, intimate relationships are monogamous) and expectancies about the behaviour of their partner.22 Both adult and adolescent women report that the suggestion of condom use has implications on intimacy as condom non-use represents fidelity, trust and commitment within the relationship.23–26 Adolescents report both that lack of condom use is an expression of trust13 and using condoms is a sign of lack of trust23 ,27 regarding fidelity and commitment to the relationship. Thus, risk perception may be less important than intimacy when adolescents are deciding whether or not to use a condom with their main partner.28 Maintaining levels of intimacy within a relationship may explain why adolescents who perceive their main partners to have other sex partners do not use condoms with that partner.13 ,29 Further, adolescents report that once their relationship is established, their perceptions of risk for an STD is based on the amount they trust their partner to practice safe sex with other partners.25 ,27 The developmental task of forming intimate relationships may overshadow concerns for STD risk.
Findings from these analyses begged the question, what does a low intimacy adolescent main partnership look like? Our post hoc analyses revealed relationship and partner characteristics that were distinct for high- versus low-intimacy main partnerships. Exchanging money and receiving material gifts from a main partner was significantly associated with high levels of intimacy in the relationship. Our results are consistent with those from a qualitative study which found that women's unsafe sexual practices were not motivated by instrumental support but that receiving money or gifts from their partner was a symbol of love and respect, qualities that implied fidelity.26 In contrast, we found that partners who were verbally abusive were significantly less likely to be high intimacy partners. Partners who ever sold drugs or gave drugs or money for sex were also significantly less likely to be high-intimacy partners. More research is needed to understand the meaning of these partner and relationship characteristics.
A major strength of this study was the ability to quantify the role of intimacy on PRSTD and condom use within adolescent main relationships. Further, our results describe the variation in intimacy within partnerships labelled as main by adolescent women. With some notable exceptions,10 ,14 ,30 much of our understanding of the role intimacy plays in HIV and other STD risk comes from qualitative interviews with adult women. Findings from the current study provide quantitative support for much of what is reported in this literature.
There are limitations to this study that highlight the need for future research. First, we did not have repeated measures within relationships, so temporal ordering could not be established. Also, while many participants contributed multiple relationships to the analysis, we did not examine these associations within individuals. Future studies should look longitudinally at whether perceived partner concurrency predicts intimacy which in turn predicts PRSTD and condom use and how an individual's relationship experiences impact their successive relationships. While our sample represents the population who bear the greatest burden of disease, African–American female adolescents, a second limitation is that this was a clinical sample, who tend to be at higher risk for STDs compared with a school-based or other non-care-seeking sample. Participants recruited from the clinic may have a higher risk perception either because they are healthcare seekers in general or because they have experienced an STD. Thus, the magnitude of our findings may be an over estimate compared with general population. However, we do not expect that there would be differences with respect to intimacy in relationships.
Condoms are a key tool for STD prevention; however, they may be in conflict with expectations about how relationships work. It is critical that future interventions acknowledge the importance of intimacy in adolescent and young adult relationships. Failure to account for the roles of intimacy in adolescent relationships may modify the effectiveness of biomedical prevention strategies (eg, PreP) as their use for STD prevention may have the same relationship implications as condoms. Reducing infection rates in sex partners through broader screening or through community-level interventions aimed at sex networks might prove to be a more effective approach to reduce PRSTD risk in young women.
Previous findings of an association between STD risk perception and condom use might be confounded by intimacy.
Condoms are a key tool for STD prevention; however, they may be in conflict with adolescents' expectations about intimate relationships.
Future STD prevention interventions must account for the importance of intimacy in adolescent relationships.
Reducing infection rates through broader screening or interventions aimed at sex networks may be a more effective approach than interventions targeting individual behaviours.
Funding This research was supported by the National Institute of Allergy and Infectious Diseases (R01-AI36986), the National Institute on Drug Abuse (F31-DA019822) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01-HD058309).
Competing interests None.
Ethics approval Ethics approval was provided by Johns Hopkins University Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.
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