Young Urban Women’s Patterns of Unprotected Sex with Men Engaging in HIV Risk Behaviors

Abstract

This study explored reasons women engaged in unprotected sex with male partners they distrusted and perceived to engage in HIV risk behaviors. Seven focus groups were held in public housing and neighborhood centers in the urban Northeast with 43 African American and Latina women. Content analysis was conducted by open and axial coding. Barrett’s theory of power as knowing participation in change and sex script theory guided interpretation. Results indicated that Patterns of Unprotected Sex is a usual practice to maintain hope, sensuality, intimacy, strategic gain, and stability with a male partner. In low power sex scripts the salient risks of HIV were buried under an awareness of oneself as having to satisfy a man and accept cheating. High power sex scripts involved women’s awareness of themselves as worthy of self care with diverse choices. High power scripts can be integrated into normative sex scripts as exemplars of more powerful ways of being and acting to reduce HIV risk.

Introduction

There is a need to explore partner relationship factors that promote unprotected sex, particularly when women are aware that their male partner may be engaging in risk behaviors (Dolcini & Catania, 2000; Jones, 2004, 2006a). For example, unprotected sex is perceived to promote intimacy, romance, and trust (Diekman, McDonald, & Gardner, 2000; Hynie, Lydon, Cote, & Weiner, 1998; Sobo, 1995). Since the most prevalent route (78%) of human immunodeficiency virus (HIV) transmission in women is sex with infected men (Centers for Disease Control Disease Control and Prevention [CDC], 2006), these concerns present implications for the design of relevant clinical interventions.

Sex scripts appear to support an implicit understanding that unprotected sex is necessary to begin or maintain a main partner relationship status (Jones, 2006a, b). Sex scripts provide a repertoire of socially shared meanings about sexual behavior (Simon & Gagnon, 1986). Scripts guide behavior because they are organized knowledge structures that spell-out the sequence of events in well-known situations (Singer & Salovey, 1991). Yet, Simon and Gagnon argue that sex scripts are dynamic, changing with social environments. Individuals and dyads also adapt the scripts with their own contemporary spin. Although several researchers have utilized sex scripts as a framework to understand sexual behavior (Emmers-Sommer & Allen, 2005; Hynie et al., 1998; Jones, 2006a, b; Krahe, 2000; Metts & Spitzberg, 1996; Parsons et al., 2004), descriptions of these well-known situations that comprise the contemporary sex scripts of young adult women in urban communities, remain understudied.

Based on findings by the first author, the current study was conducted to explore urban women’s views about engaging in unprotected sex with male partners whom they perceive to have engaged in HIV risk behaviors. In particular, women’s views on sexual pressure and dyadic trust were sought, since these variables were previously found to relate to women’s HIV sexual risk (Jones, 2004, 2006a). Sexual pressure is based on gender stereotypical expectations to have sex. One dimension of sexual pressure is the belief that men expect women to engage in sex and that women should respond or he will find someone else. Another is the pressure to show trust by engaging in unprotected sex (Jones, 2006a).

A framework of Barrett’s theory of power as knowing participation in change (1998) and sex script theory (Simon & Gagnon, 1986) was used to guide analysis and interpretation. Using this framework, the themes and relationships among themes could be conceptualized as low power sex scripts and high power sex scripts. Power as knowing participation in change is comprised of awareness, choices, feeling free, and involvement in change (Barrett, 1998). Interpreted in the context of HIV sexual risk behavior, power involves women’s awareness of their own value as women; awareness of the choices they make and whether these choices are made intentionally; whether they feel free to pursue their choices; and the manner in which they are involving themselves in realizing these choices. A description of low and high power sex scripts could be a basis to frame health promotion messages that popularize high power sex scripts among young urban women.

The purpose of this study was to (1) gain understanding of the reasons young adult urban women in an HIV epicenter engage in unprotected sex with men for whom they have low trust and perceive to engage in HIV risk behaviors; (2) to explore sexual pressure in regards to sexual risk behavior; and (3) to elucidate the conditions under which low and high power sex scripts operate in urban women’s dyadic relationships with men. The themes emerging from this study comprise the basis of the development of soap opera type video vignettes which will be evaluated as a potential intervention to reduce HIV risk behaviors.

Methods

Procedure

Following approval from the Institutional Review Board to conduct the Women to Women Study of Relationships with Male Partners study, seven focus groups with a total of 43 women were held in neighborhood settings in Newark and Jersey City, New Jersey. This number of focus groups was sufficient to validate emerging themes and to answer the research questions.

In Newark, the principal investigator (PI) and research assistants (RAs) met with leaders of a community based organization that provides services at sites throughout the city. Recruiters were identified to facilitate on-site recruitment. Data were collected at a job training center, an after school program located in a public school, and a childcare center. In Jersey City, data were collected at three different public housing developments. The Director of Social Services of the citywide public housing developments selected the sites, made essential arrangements, and identified a recruiter for each site. The recruiters met with the PI one or two weeks before data collection for an orientation to the study protocol. At this time, the recruiters were provided with recruitment flyers for distribution within their respective site.

A purposive sampling strategy (Miles & Huberman, 1994) was used to identify women between the ages of 18 and 25 who were in a sexual relationship with a male partner within the past three months, and had the ability to speak and understand the English language. Potential participants directly phoned the PI for a final determination of eligibility for the study. A follow up letter, sent to each eligible participant, contained details about the location and time of the focus group meeting and that child care would be provided, if required. Each participant received an honorarium of $25.

Data Collection

Data were collected via focus group since the interaction among participants offers opportunities for sharing and comparing experiences (Morgan, 1997) that are missing from individual interviews. The groups were relatively homogeneous in that all members were low-income, late adolescent or young adult women, who lived in cities with a relatively high incidence of HIV/AIDS. The members of six focus groups were predominately African American; one group was entirely Puerto Rican. Participants readily acknowledged that unprotected sexual intercourse with men whom women did not trust and perceived to engage in risk behaviors was a well-known occurrence. Because recruitment occurred in neighborhood settings or public housing developments, most participants were acquainted with each other. Still, according to the study protocol, women selected pseudo names and addressed each other using the pseudo names to maintain their confidentiality on the audio tapes. Their familiarity with each other contributed to the natural, lively, frank, and relatively uninhibited discussion.

The PI moderated and a RA co-moderated each focus group. The RA was a Masters prepared nurse practitioner whose ethnic background was similar to the target sample. Additionally, three RAs who were also of similar ethnic background assisted with the focus groups. After each focus group, the RA’s observations were shared with the PI and recorded.

The interview guide was developed from previous study findings by the first author (Jones, 2004, 2006a) concerning trust, sexual pressure, and HIV sexual risk. The moderator asked the following questions. Can you describe a situation when you or a friend [Probe: How did you deal with it?]:

Didn’t trust a male partner but unprotected sex happened anyway? Felt unsure or thought that maybe a male partner had sex with other women but unprotected sex happened anyway? Felt pressured to have sex or not use condoms? Felt that men have a right to expect sex from their woman? If you were talking to a friend, how you would describe a relationship with a man where the woman has equal say about whether or not to have sex? Anything else you would like to add?

Additional questions concerning views about high risk sexual practices, such as, unprotected sex with men who have sex with men or men who inject drugs, views about men on the down low (men who have sex with men but self-identify as heterosexual) (King, 2004), and anal sex were also asked.

Data Analysis

Both the PI and the RA attended all focus group meetings. All focus group meetings were audio taped, transcribed by the RA, and reviewed by the PI. The transcripts were checked for accuracy against the original tapes and written notes taken during and immediately after the focus groups to assure consistency.

Content analysis was conducted by the PI and the RA, and followed Strauss and Corbin’s (1990) method of open and axial coding. HyperResearch™ software was used for coding and retrieval. Use of this software enabled the researchers to hyperlink codes to the original data in order to stay grounded in the data (Strauss and Corbin), and so data could be accessed easily when there were differences in interpretation between the two analysts. Using HyperResearch™ the original text was readily retrieved by clicking on the code. Finally, the software was useful in creating a conceptual structure (Miles & Huberman, 1994) through its mapping capability. Mapping categories permits higher levels of abstraction.

A cross case analysis was used. With this approach, each focus group was a case and the codes were analyzed across cases (Miles & Huberman, 1994). Codes were applied to narrative units that concerned a story or a particular focus of discussion. The narrative units were as long as a few paragraphs, or as short as one phrase (Kidd & Parshall, 2000). The coding process yielded 850 open codes. The next phase entailed placing codes with similar meaning into categories. By asking questions and making comparisons, each code was placed within categories until consensus was reached between the PI and RA.

Second order coding involves the interpretive phase of finding patterns and relationships among categories (Crabtree & Miller, 1999). Strauss and Corbin describe this phase as axial coding. In axial coding, categories are discussed in relation to the central phenomenon (Strauss and Corbin). Given the nature of the research problem, the central phenomenon was Patterns of Unprotected Sex. Following the axial coding paradigm, relationships among the categories involved deciding which were antecedent to the central phenomenon, which were a consequence of the central phenomenon, what action was required for the central phenomenon to occur, and what intervening or environmental concerns formed the context of the central phenomenon.

The three dimensions of power as knowing participation in change; awareness, choices, and feeling free were conceptualized to be antecedent to the central phenomenon. Involvement in change was conceptualized as action/interaction, or those actions required for the central phenomenon to occur. Some categories were conceptualized as the consequences or cost of unprotected sex. The axial coding process involves locating the properties of the categories along a dimensional range, such as low to high. Low power sex scripts and high power sex scripts emerged according to the properties of the antecedent categories, action/interaction categories, and consequences of Patterns of Unprotected Sex.

Ongoing memos followed each content analysis session. These memos described the rationale for placing codes under certain categories and serve as an audit trail. Whenever the interpretive meaning of a code was questioned, the PI or RA consulted the original text. Results were compared to an ongoing review of the relevant literature.

Results

Participants

Of the 43 women, 30 were African American, 10 were Latina, and 3 were of non-Spanish speaking Caribbean background. The mean age was 21.6 (SD = 2.5). Eighteen women completed high school, 12 did not complete high school, and 13 had one to two years of college. The majority (n = 34) had a main partner; the rest had occasional partners. Most of the women had children, 13 did not. Twenty-four women (55.8%) were employed; most women working outside the home worked less than 30 hours per week. The majority (79%) earned less than $10,000 annually.

Results of Content Analysis

The central phenomenon is Patterns of Unprotected Sex. The term Patterns is used to indicate that unprotected sex is a usual practice characterizing low power sex scripts. The themes categorized into awareness, choices, feeling free and involvement in change, as well as the consequences of Patterns of Unprotected Sex, and Environment in which the Patterns occur, are described below. The associations of these themes into low and high power sex scripts, and examples of how these were applied to develop the stories that were later scripted into urban soap opera video vignettes are described in Table 1.

Table 1.

Themes reflecting dimensions of power comprising low and high power sex scripts to create urban soap opera video vignettes

Dimensions of power	Themes comprising low power sex script		Represents a range of low to high power themes	Themes comprising high power sex script	Examples of how themes were scripted into video vignettes
Awareness	Young girls throwing themselves at men.	Have to satisfy the man.	When I want some I get some	You don’t own me
	“Hanging around with someone who sleeps around” “Get her- I did last week” “They act like boys-hit and run”	“If I don’t want sex he goes to them chicken heads.” “Expecting sex is all right if they are in a relationship” “As long as you’re doing your job he won’t leave.” “Got to give it to him”	“I like to do it raw.” “Sex is good with him” “Females are not being pressured for sex- they want it”	“Expecting sex is not all right” “Put yourself first -can’t always put the man before you” “It’s ok not to have sex with just anybody” “ Don’t disrespect me- I won’t disrespect you” “No means no”	The heroine, Toni, works full time in a low wage job. She has a 10-year-old child. Mike is her live-in boyfriend of five years. She engages in unprotected sex with Mike in spite of mounting evidence that he and Valerie are going to a hotel after work. At the end of the story, Toni invites the viewer to come with her as she revisits each high risk scene- only this time she acts with higher awareness and exercises different choices; attributes of power.
Choices	What he’s doing for her		Focus, what you want is the man you get	Focus, know what you want
	“As long as he takes care of me” “As long as he comes home to me” “As long as I’m the main girl” “The other girl shouldn’t get as much as me” “I just wanted him to love me” “Girls fending for themselves reach out to men for comfort” “Confuse sex with love” “Buys me things” “A child needs a daddy”		“I rather he lie than tell me the truth,” “Lying means he cares,” “Hiding that he’s cheating is respecting me” “Whenever he’s in the street, I wonder- is he doing me wrong again?” “He should use condoms with the other girl” “Look for a man that’s ready to be in a relationship” “A good man doesn’t see other women” “I want a man who respects himself” “There is a soul mate out there somewhere” “A good man takes care of his responsibilities” “He will treat you the way you allow him to treat you”	“Got to better myself” Focus on school.focus on my child…my job.”	As long as Mike comes home to Toni every night, she prefers that Mike lie than tell her the truth. In the power scenes, when Toni revisits each high risk situation, she invites the viewer to come and explore her other choices. These are: 1) Toni is not ready to leave Mike. She tells him that he can stay but must get HIV tested and use condoms; and 2) Toni is ready to tell Mike to leave. In this power scene, Toni tells Mike that she is looking for someone who respects her.
Feeling free	Stuck in their ways			Girl power
	“Forgive him and leap into bed.” “Need him” “Always depending on a man” “Cant be alone” “He was my world and now he’s gone” “Disrespecting me and I still wanted him” “Mind control” “He puts me down”		“When I set my mind to something, I don’t let anything get in my way”	“Don’t give up on a friend” “Lifted up by a friend” “Trying to tell my friend her boyfriend was cheating”	Toni often forgives Mike because she is not ready to be alone. Diamond is Toni’s best friend. Diamond reminds Toni that she has choices. Toni feels Diamond’s unconditional support as she struggles with difficult choices.
Involvement in change	Hope it will get better	Block it out	Strategize	Sensuality, Take the power
	“Hanging onto him hoping it would get better, so we could be a family again”	“She was in love and blocked out what everyone said” “What you don’t know won’t hurt you” “Don’t think about AIDS during sex” “Focus on the relationship not what he may or may not be doing” “Didn’t want to get up”	“Sex to keep him” “Sex to make up”	“Tempted he looked so good” “Carry a condom so you know you got em” “Condoms- if he’s sleeping around” “I put them in his wallet in case he cheats.” “HIV tested before we stopped using condoms”	Toni kept hoping things would get better and that Mike would change. She acted on her feelings and blocked out Diamond’s advice. When Toni revisits the high risk scenes, she enacts a sensuous scene whereby she carries the condoms, playfully tells him they can feel good, and convinces Mike to use condoms.
Consequences/Cost	Regret and stress on your brain	Lose trust	Pregnancy, catch something	Get tired of it	Valerie is pregnant and learns that she is infected with Gonorrhea. Mike is also infected with Gonorrhea. Valerie calls Toni and tells her. Toni forgives Mike. At first, Toni and Mike use condoms but after a week, Mike convinces Toni to resume unprotected sex. Mike receives a call from the STD clinic partner notification team. He has been named as a sex partner by someone who was recently HIV infected. Mike visits Steve who tells Mike he is sorry he had to name him as his sex partner.
Environment	Not one person can say they don’t know a person with HIV/AIDS	HIV and AIDS are not talked about much anymore	Unprotected sex with a cheating boyfriend happens everyday	Men having sex with men is an issue but its not my issue

Note: Power involves awareness of what one is choosing to do, having a tendency to explore available choices, feeling free to put choices into action, and participating to help make the changes happen

Awareness of Yourself as a Woman

Lower awareness of oneself as a woman involves a diminished view of one’s personal worth. The theme Young Girls Throwing Themselves at Men refers to women who view their bodies as commodities. Such women were described as “Chicken Heads” who are “hangin around with men who sleep around” and “taking big chances.” The theme Have to Satisfy the Man reflects the view that sex is a requirement to hold onto a male partner. “If I don’t want sex he goes to them chicken heads” and “As long as you’re doin your job he won’t leave.” When I Want Some I Get Some describes women who initiate sex, and that, “females are not being pressured for sex, they want it” and “like to do it raw.” A higher level of awareness in relation to the central phenomenon was illustrated by the theme Expecting Sex is not All Right and You Don’t Own Me. Examples of these themes are: a woman should “put herself first; can’t always put the man before you,” and “strong independent Black Woman.”

Being Aware of Choices and Making Choices Intentionally

Choices, means being aware of a range of possible choices, and being aware of the reasons for making a particular choice. Reasons for staying with a male partner perceived to engage in risk behaviors are described by the theme, What He’s Doing for Her. Examples are; “as long as he comes home to me,” “as long as I’m the main girl,” and “I just wanted him to love me.” What He’s Doing for Her also refers to the material things that he is providing, such as, “gifts” or “he pays the bills.” It may be filling the role of a father because “a child needs a daddy;” or it may represent the “status” of being with a “popular man.” If women know their partner is cheating, then, What He’s Doing for Her means accepting a trade off to hold on to the relationship. The theme, Focus, What you Want is the Man you Get pertains to specific choices in male partners. For example, some women described their partners as men who hang out all night. There was also the description of more powerful choices such as, seeking “a soul mate,” finding “a good man who takes care of his responsibilities,” and one who is “worried about his health as well as mine.” A disturbing finding was the preference for a male partner to lie in order to sustain the myth of monogamy. “I rather he lie than tell me the truth” and “lying means he cares.” Focus, Know What You Want is a theme depicting choices that transcend relationships with men. These choices involve remaining focused on a goal, such as, going to school, working, or raising a child. Focus, Know What You Want means women avoid unprotected sex out of concern that the consequences could deter them from their goals.

Feeling Free to Put Choices into Action: Stuck in Their Ways and Girl Power

Feeling free to put choices into action refers to how free the person feels to pursue her intended choices. Feeling Free is described by the themes Stuck in their Ways and Girl Power. Stuck in their Ways means feeling trapped in patterns of relationships with men. Particularly since these relationships did not achieve what women had intended, such as, to be loved or the status of main partner. Stuck in their Ways involve “always depending on a man,” “disrespecting me and I still wanted him,” and “jumped back into a relationship that was no different.” Stuck in their Ways means women ‘‘Kick him out and let him back in,” “Forgive him and leap into bed.” Some women used the term “mind control” to describe their obsession with a partner with whom they remain unhappy. In contrast, Girl Power is the antidote to isolation. It is the experience of a friend’s unconditional support. Women described how much it meant to them to have a friend who was always there no matter how often she repeated Patterns of Unprotected Sex. “I didn’t feel so vulnerable and afraid with no one to turn to.” Girl Power means, “Tryin to tell my friend her boyfriend was cheating.” Even if she doesn’t listen this time, “Don’t give up on a friend,”

Involvement in Change: Participating to Help Make the Changes Happen

Involvement in change is those actions required for Patterns of Unprotected Sex to occur. These themes reflect how women involve themselves in realizing their choices. Hope it Will Get Better reflects the importance of the promise of better times. Women described “hanging on to him,” and “hope he’ll change and want us to be a family.” Hope it Will Get Better means that women “block out what everybody says” because you are “blinded by love.” Unprotected Sex as a Strategy means that women know they want a long-term relationship and they “strategize from there.” The statement, “Sex to keep him, sex to make up” is an example of unprotected sex as a strategy. In contrast, Sensuality describes spontaneous unprotected sex. “In the heat of the moment things got out of control,” or “I didn’t want to get up.” Take the Power describes women who insist that a condom is used and carry the condom, particularly when they think their partner is having sex with others. Some women “put them in his wallet in case he cheats.” Others described how hard it was to ask a partner to use a condom after they had already initiated unprotected sex. Take the Power means telling a man, “just do it for me,” “to make me happy,” and “this way we’re sure.” It also involves an attitude that one can “feel good” using a condom. Participants described their experiences with various types of condoms that facilitate sexual pleasure.

Consequences

After unprotected sex with a partner whom they suspect had engaged in HIV risk behaviors, women were often worried, describing Regret and Stress on Your Brain. Worry was sometimes experienced as panic. Panic precipitated HIV testing; after the fact. Losing Trust was an assessment of their partner’s behavior. Participants described Losing Trust when they became infected with a sexually transmitted infection (STI). Although they were Losing Trust, their behavior did not change. The theme, Get Tired of It, is used to describe the moment when women do change their behavior and stop engaging in Patterns of Unprotected Sex.

Environment: The Context of Patterns of Unprotected Sex

Themes concerning the environment describe the context in which Patterns of Unprotected Sex occurs. Women were aware of the prevalence of HIV infection in the community. Most of the participants stated they had known a relative or someone in the community with HIV or AIDS. However, “HIV and AIDS are not talked about much anymore.” Cheating was described as commonplace, “unprotected sex with a cheating boyfriend happens everyday.” Increasing the potential for undiagnosed infection, women believed “men don’t like to go to the doctor.” When asked about men on the “down low,” women in several focus groups responded “men having sex with men is an issue but not my issue.” However, several participants explained, “you never know if they’re on the down low,” and “that’s playin dangerous games with women.” Women were aware of the availability and cost of condoms.

Discussion

This study explored reasons women engage in unprotected sex with a male partner they distrust and perceive to be engaging in HIV risk behaviors. Further this study explored contemporary themes indicative of sexual pressure as a function of stereotypical gender role and power as it manifests in urban women’s dyadic relationships with men. Interpretation of findings in regards to women’s HIV sexual risk behavior was guided by sex script theory and the theory of power as knowing participation in change. Using this frame-work, the themes and relationships among themes were conceptualized as low power sex scripts and high power sex scripts in young urban women. The objective of this approach was to provide rich descriptive detail to develop stories and scripts for urban soap opera video vignettes. The vignettes were subsequently pilot tested as a potential intervention. The lead characters in the vignettes dramatize the low power scripts involving high HIV risk, and then reenact the same scenes with high power sex scripts that are based on higher awareness, diverse choices, feeling free, and involvement in change.

The findings are based on content analysis of stories told by predominately low income African American and Puerto Rican late adolescent and young adult women in the urban Northeast. The findings are not generalizable to women in other regions, ethnicities, or age groups. However, similar stories were told by women in both cities lending support to the validity of the findings for this particular population.

Low Power Sex Scripts

Patterns of Unprotected Sex is a usual pattern to maintain hope, sensuality, intimacy, and strategic gain (win him, keep him) with a male partner. Personal awareness of a high incidence of AIDS in the neighborhood, perceived male partner cheating with other women, and acknowledgement of men having sex with men as someone else’s problem, was the environmental context within which Patterns of Unprotected Sex occurs. Women’s awareness of themselves was central to feeling unworthy of self-care as exemplified by Young Girls Throwing Themselves at Men. With low power sex scripts, the salient risks of AIDS were buried under an awareness of having to satisfy a man; focusing on narrow choices, such as, to accept cheating “as long as he comes home;” and feeling stuck in patterns of unprotected sex by clinging to the eternal hope that things will get better. Low power sex scripts mean women pursue their choices in ways these choices were unlikely to be realized, such as hoping to have a long-term intimate relationship with a partner engaging in sex with others. Women engage in a pattern of unprotected sex as a strategy to attain or hold onto main partner status. Bauman and Berman (2005) also noted that expectations for future commitment may be more important than the length of the relationship in choosing to engage in sex.

Have to Satisfy a Man required that women focus awareness on their partner’s needs. If a woman preferred that her partner lie to cover-up cheating so that she could continue receiving What He’s Doing for Her, she often felt Stuck in her Ways. Bowleg, Lucas, and Tschann (2004) also reported that women accepted cheating as long as the partner came home every night.

Women Lose Trust and remain Stuck in their Ways continuing to engage in unprotected sex because they Block it Out. Women with a low level of feeling free repeat the same patterns with the same or different men, until one day, their feelings and behavior change as they Get Tired of It. This theme resonates with the concept of awakening whereby women reconstruct risk and change their behavior (Mallory & Noerager Stern, 2000). After recurrent regret, stress, and losing trust, Get tired of It represents an epiphany; when women’s feelings and behavior change.

High Power Sex Scripts

According to the theory of power as knowing participation in change, the act of asking or stating that condoms be used involves women’s awareness of themselves as worthy of self care, with diverse choices, and feeling free to state their position against pressure to have sex. High power scripts mean women are not Stuck in their Ways and feel connected to others, a characteristic of Girl Power. The theme Expecting Sex is not All Right, You Don’t Own Me reflects a sense of sexual autonomy, a key aspect of sexual health (Morokoff et al., 1997) that may be important in resisting stereotypical gender expectations to have sex (Jones, 2006a). Women who Take the Power carried their own condoms and communicated a matter-of-fact perspective to a partner who resists condom use. Metts and Spitzberg (1996) also pointed out that the manner in which women frame the request for men to use condoms is not as important as simply making the request.

The theme When I Want Some, I Get Some challenges the stereotypical view of women’s passivity and offers further support for women’s sensation seeking (Jones, 2004; Kalichman & Rompa, 1995). The theme, Take the Power, emphasizes pleasure with condom use. These themes can be framed in public health messages to appeal to assertive and sensation seeking women. A similar approach was taken by Palmgreen, Donohew, Lorch, Hoyle, and Stephenson (2001) who found that interventions to reduce substance use among sensation seekers were more effective when novelty, surprise, and strong emotion were integrated. Similarly, Take the Power, may be formulated into health promotion messages to counter the view that condoms are to be used with the “other” woman, but not the main partner. These messages can stress the perspective that condoms can enhance pleasure, relieve stress, and show men care, in order to appeal to intimacy needs with main partners whom women suspect are not monogamous.

Patterns, Sex Scripts, and Change

The colloquial low power sex script tends to predict the positive outcomes of unprotected sex and minimizes HIV risk. Like a fall back position, the low power sex script characterized by Patterns of Unprotected Sex, provides a readily available schema of stereotypical expectations and behaviors. However, new experiences may be associated with stereotypes or memories of previous experiences (Fiske, 1982, 2004; Smith & Kirby, 2000; Stacy, Newcomb, & Ames, 2000). Stacy et al. (2000) suggest that health promotion messages that are associated with normative behavior patterns are more likely to be adopted. According to this view, by popularizing high power sex scripts and associating these with low power sex scripts, the new behavior will more likely be adopted. This is the basis to the development of the soap opera type video vignettes. High power themes that were evident in the focus groups, such as, Girl Power, Expecting Sex is Not All Right, Take the Power, and You Don’t Own Me, were integrated into normative low power relationship scripts. The intent is to create exemplars of more powerful ways of being and taking action to reduce HIV risk.