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. Author manuscript; available in PMC: 2014 Jul 30.
Published in final edited form as: Arch Sex Behav. 2006 Dec 21;36(2):269–279. doi: 10.1007/s10508-006-9092-9

Sexual Scripts of Women: A Longitudinal Analysis of Participants in a Gender-Specific HIV/STD Prevention Intervention

Shari L Dworkin 1,2,3,✉, Sharlene T Beckford 4, Anke A Ehrhardt 5,6
PMCID: PMC4115796  NIHMSID: NIHMS605470  PMID: 17186128

Abstract

Project FIO (The Future Is Ours) was a three arm randomized controlled HIV prevention intervention trial carried out with heterosexually-active women in a high sero-prevalence area of New York City. The trial was effective and women in the eight-session intervention arm were significantly more likely to report decreased unsafe sex or no unsafe sex compared to controls at one month and one year post-intervention. The current investigation was a qualitative analysis of women’s sexual scripts at baseline and one year follow-up for a randomly selected subsample of participants in Project FIO. We examined the domains of sexual initiation, pace setting, sexual decision-making, communication about sexual needs, and the timing of condom introductions in the experimental and control arms at baseline and one year follow-up. At one year follow-up, among both the experimental and control arms, results showed changes away from male-dominated and toward female-dominated sexual initiation and sexual decision-making. Among both the experimental and control arms, results also showed that trial participants shifted from a late condom introduction (right before intercourse) toward much earlier mention of condoms (e.g. during a date). The fact that shifts in sexual scripts at one year follow-up occurred in both groups is likely reflective of the degree to which a lengthy assessment interview facilitated comfort with discussing and imagining new sexual behaviors, even for control group participants who did not receive the intervention. The value of empirically assessing sexual scripts in HIV/AIDS prevention and doing so longitudinally is assessed in light of the goals of HIV prevention interventions.

Keywords: Sexual scripts, Gender-specific HIV/AIDS prevention interventions, Qualitative methods, Women

Introduction

Since the year 2000, the proportion of women who acquire HIV/AIDS from heterosexual contact has outpaced injection drug use, and heterosexual contact now accounts for the large majority of the identifiable risk for women in the United States (Centers for Disease Control and Prevention, 2002, 2003). To meet the need arising from these trends, HIV/AIDS prevention intervention researchers in the United States have increasingly shifted from gender-neutral to more gender-specific and empowering interventions (Exner, Hoffman, Dworkin, & Ehrhardt, 2003; Gupta, 2001). As a result, strong emphasis has been placed on understanding and changing the contexts that shape risk in heterosexual relationships. One useful but relatively unexamined window into the way in which contextual aspects of heterosexual relationships operate is known as the sexual script.

Sexual scripts are mutually shared conventions that guide individuals to interdependently carry out sexual scenarios. Scripts are constituted by three interrelated realms known as cultural scenarios, interpersonal scripts, and intrapsychic scripts (Gagnon, 1990; Laumann & Gagnon, 1995; Simon & Gagnon, 1984, 1987). Cultural scenarios are derived from diverse social and institutional sources (media, peers, family, schools, religion) and are the norms that guide sexual behavior at the societal level, helping to determine the who, what, where, when, why, and how of sexual interactions. The interpersonal script includes individual interpretation of cultural norms, and allows for the way in which mutual interactions shape sequences of sexual action. Lastly, there is the intrapsychic realm, which is defined as the motivational elements that produce commitments to a particular sequence of events, including desires and fantasies.

There is some suggestion that sexual scripts may be changing in contemporary U.S. culture for both heterosexual men and women (Dworkin & O’Sullivan, 2005; Ortiz-Torres, Williams, & Ehrhardt, 2003; Seal & Ehrhardt, 2003; Segal, 1995). Research has underscored how men do not simply view sex as a conquest but also seek emotionality, commitment, and love through sex, although this may be dependent on whether partners are casual or committed (Seal & Ehrhardt, 2003; Seal, Wagner-Raphael, & Ehrhardt, 2000; Segal, 1997). Other work emphasizes how women have moved beyond passivity or responsiveness to men’s sexual advances to include their own initiation and pleasure-seeking, persuading reluctant male partners to have sex, and experiencing success at negotiating safer sex (Anderson & Aymami, 1993; Anderson & Sorensen, 1996; Exner et al., 2003; Kamen, 2003; O’Sullivan & Byers, 1993, 1996). Recently, research has also underscored how experiences with rigid definitions of gender in heterosexual relationships can, at least in part, translate into the desire to move away from traditional scripts (Dworkin & O’Sullivan, 2005; Ortiz-Torres et al., 2003). Moving away from dominant cultural scripts may not only be rewarding at the individual or interpersonal level, but might also have important health implications given the ways in which overconformity to traditional gender norms has been found to be associated with HIV risk (Campbell, 1995, 1999; Ortiz-Torres et al., 2003; Seal & Ehrhardt, 2003; Seal et al., 2000).

Sexual scripts are vital for an analysis of safer sex practices since communication, decision-making, and the ability to shape one’s own and another’s actions are central to sexual negotiations (Mahay, Laumann, & Michaels 2001; Ortiz-Torres et al., 2003; Pulerwitz, Gortmaker, & DeJong, 2000). Adherence to traditional scripts may put both women and men at risk for HIV, with men feeling pressured to push for sexual opportunities regardless of safety concerns, and women feeling distanced from their own sexual needs, or finding it difficult to negotiate a male partner’s insistence on unprotected sexual encounters effectively (Gupta, 2001; Logan, Cole, & Leukefeld, 2002; Seal & Ehrhardt, 2003; Wagner, Seal, & Ehrhardt 2001; Williams, Gardos, Ortiz-Torres, Tross, & Ehrhardt, 2001). Many women report difficulty negotiating safer sex practices with male partners (Ehrhardt, Exner, Hoffman, Silberman, & Yingling, et al., 2002; Fullilove, Fullilove, Haynes, & Gross, 1990; Gómez & VanOss Marín, 1996; Gupta & Weiss, 1993), at times acquiescing to unsafe sex in order to sustain relationships (or to avoid conflict or abuse) (Sobo, 1993). These actions are partly shaped by unequal economic and social status, which have been found to put women at a distinct disadvantage in terms of negotiating safer sex (Exner et al., 2003; Gupta, 2001).

Given the links between HIV/AIDS research and sexual scripts, researchers are beginning to intervene more formally on the different levels of scripts as a part of HIV/AIDS prevention. That is, some have sought to critically deconstruct and rewrite traditional gender scripts so that individuals can become aware of how the cultural, interpersonal, and intrapsychic arenas shape sexual beliefs and practices (Ahlemeyer & Ludwig, 1997; Paiva, 2000). Approaches that elucidate and break down the specific components of the sexual script are key since this provides women and men with the specific tools that are necessary to evaluate and/or change sexual practices. Despite these recent approaches, empirical analysis of sexual scripts within HIV prevention trials remains scant (Ortiz-Torres et al., 2003). No published research to date has empirically examined how sexual scripts change as a result of participation in an HIV/AIDS prevention intervention trial and whether these changes have important implications for safer sex practices. The goal of the current study was to examine whether and how changes in sexual scripts occurred for a randomly selected subgroup of women who participated in Project FIO and, if so, to assess if such changes were different for the experimental and control arms. Project FIO (The Future Is Ours) was a manualized, group-based intervention trial designed to reduce sexual risk among heterosexually-active women from a high HIV sero-prevalence area of New York city.

A previously published qualitative analysis explored sexual scripts in Project FIO at baseline, and compared the proceptive aspects of courtship that preceded sexual encounters with the sexual phase itself (Ortiz-Torres et al., 2003). The proceptive phase has been deemed vital in terms of defining the contextual features that surround sexual scenarios (Beach, 1976). The current investigation provides an analysis of changes only in the sexual phase of women’s scripts given that sexual negotiations and condom use were central to the goals of this particular HIV/AIDS prevention intervention. Specifically, we examined the domains of sexual initiation, sexual pacing, sexual decision-making, communication about sexual needs, and the timing of condom introductions at both baseline and one year follow-up.

Method

Participants

In Project FIO, women (N = 360) who were family planning clients seeking gynecological health, pregnancy prevention, or HIV/STD screening and treatment services were recruited from the waiting room of a Planned Parenthood clinic in Brooklyn, New York from 1994–1996. To be eligible for participation in FIO, women had to be a client of the above clinic, report heterosexual activity within the prior year, be between 18 and 30 years old, have unknown or negative HIV serostatus, have no history of receiving a blood transfusion from 1980 to 1985, report that they were not currently pregnant or planning to become pregnant, report no intravenous drug use in the past year, and be comfortable with spoken English. Eligible women who were willing to participate had a baseline interview and were subsequently randomized into one of three study arms: an eight-week or a four-week intervention condition or an assessment-only control group (for details on the theories, randomization procedures, and subject flows from the parent study, see Ehrhardt, Exner, Hoffman, Silberman, Leu, et al., 2002; Miller, Exner, Williams, & Ehrhardt, 2000). Efficacy of the trial was assessed comparing women randomly assigned to an 8-session condition vs. a 4-session condition vs. a control condition at one-month, six-months, and twelve- months post-intervention. The control condition did not receive any of the intervention workshops, but did receive an in-depth two hour psychosocial assessment interview at baseline and one month, 6 month, and 12 month follow-ups. Control participants were scheduled to be interviewed during the same time intervals as their respective intervention group participants.

Similar to the parent study, this randomly selected sub-sample (N = 45) of study participants was ethnically diverse (66.7% Black or African-American, 24.4% Latina, 8.9% Caucasian or other). The mean age was 22.2 years, many women (55.6%) were enrolled in secondary or post-secondary educational programs, and several worked either full or part-time (37.8%). Most women (82.2%) had completed high school, and 42.2% of women had children. Approximately one third of the women (34.9%) reported total household incomes below the poverty level.

The randomly selected subsample of women used in the current analysis also reflects the risk profile of the participants in the trial, which was a group of women who were at risk for HIV and other sexually transmitted diseases. Sixty-seven percent of women reported at least one lifetime STD diagnosis. Participants’ risk was not driven by a pattern of numerous partners. While 91.1% of the women in our randomly selected subsample were sexually active in the past three months, 78% of this group of women reported only one sexual partner in this time. In terms of partners’ risk, 57.5% of women were certain that their main partner did not have other partners since they had been sexually involved, and 50% knew their partner’s HIV status. Furthermore, condom use was low, with 80% of these women reporting that they did not use a male or female condom consistently in the previous three months.

Procedure

The current investigation examined women’s sexual scripts at both baseline and one year follow-up for a randomly selected subsample of participants in Project FIO (N =45). The random sample that was selected for the current analysis was drawn from the same pool of interviews that were randomly selected from the previous qualitative baseline analysis (Ortiz-Torres et al., 2003). The sample was constituted by randomly selecting equal numbers from the three intervention arms: 15 from the eight-session arm, 15 from the four-session arm, and 15 from the control group. The same 45 women were analyzed at baseline and one year follow-up in order to provide a qualitative analysis of change. In six instances where follow-up data were not available for both baseline and one year follow-up time points, six new interviews were randomly selected, and transcription of interviews was carried out.

Given the similarities between women’s narratives in the eight-session and four-session arms at both baseline and one year follow-up, the analysis that follows combined the two experimental arms (N = 15 each) into one experimental group (N = 30). This experimental group was compared to the control group (N= 15) and examined in terms of change over time. We made this methodological choice given our main interest in whether those exposed to the intervention arms differed from controls. Finally, also of interest was whether any changes in women’s sexual scripts over time were in a direction that may have positive implications for safer sex practices.

The analysis was not stratified by race/ethnicity given that stratification by race was not part of the original research design for the parent study and the sample was predominantly African-American (N =30 of 45 women) and, therefore, there were very small N‘s for the remaining racial/ethnic groups. This made meaningful comparisons across racial groups difficult (N = 4 Caucasians, N = 11 Latinas). Additionally, the one month or six month follow-up assessment points were not selected for the analysis given a central concern with the types of changes that participants maintained at the time point farthest from baseline. Finally, since this was a small qualitative study, it was not powered to quantitatively discern whether there were statistically significant differences over time on script domains. Instead, we focused on qualitatively characterizing the content of women’s narratives at baseline and one year follow-up.

Measures

During the interview, the interviewer explained that:

The next part of the interview is more like a conversation. We’re interested in the kinds of things that go on between women and men when they get into a sexual relationship. So I’d like you to imagine that you’re out with a guy– you may have dated him once or several times. You know you’re both attracted to each other and you can feel each other’s sexual interest. I’d like you to tell me your most attractive, most romantic fantasy or idea about how you would end up together, starting with your feelings about why you’d want to be with this person, taking it step by step up to where you’d end up together sexually.

Participants were asked semi-structured qualitative questions and probes about the following domains: (1) women’s involvement and that of their partners in the scenario; (2) communication strategies used during the encounter, whether direct, indirect, both, or neither; (3) the context of the sexual scenario; (4) the initiation and sequencing patterns when moving from romantic encounter to sexual scenario; (5) whether condoms were part of the ideal encounter or if condoms were perceived as “ruining” an ideal sexual encounter; and (6) if condoms were part of the ideal encounter, when during the relationship condoms would be introduced.

To ensure masked coding of the interviews, a random number generator was used to replace original participant identifiers. Two coders who were external to the interviewing process for the parent study, but who were formally trained in qualitative methods, carried out the coding and analysis. Coders were masked to condition throughout the coding process. To establish a codebook, six interviews were randomly selected and independently evaluated using an open coding process employed during the initial phase of coding often deployed in qualitative research (Lofland & Lofland, 1995; Spradley, 1979; Strauss, 1987). From this initial process of broad category generation, an additional six randomly selected interviews were coded. After a second round of coding, coders met to ensure full refinement of primary and secondary categories referred to as focused, intensive, or axial coding (Berg, 2001; Dey, 1993; Lofland & Lofland, 1995; Strauss & Corbin, 1990). Once the full range of categories was established, the remaining interviews were double coded independently by the first and second authors.

The domains of sexual initiation, pacing, and decision-making were coded by drawing on the same categories that were developed in the previously published qualitative study (Ortiz-Torres et al., 2003). That is, women’s sexual script domains were coded as “female-dominated,” “male-dominated,” or “mutual” depending on how women described these domains. Keeping these designations allowed the research team to keep standardized definitions over time, facilitating an analysis of change. Communication about sexual needs and communication about condoms were coded both in terms of timing (e.g., when discussions took place, if these occurred before, during, or after sex) and type of communication (e.g., types of communication used, such as direct requests, no talking, body language, or “sexy talk” to eroticize safer sex). Following independent coding of these transcripts, decision trails were noted and documented, and the overall concordance rate across coding categories was calculated to be 92% across the interviews. To calculate concordance, we drew upon a formula developed internally by our senior-level qualitative research methods consultants. The formula is: the number of categories that are correctly coded by a single rater divided by the total number of final codes plus the number of omissions (number of total codes that a single rater did not originally code) plus the number of comissions (number of codes that a single rater initially coded but that were not included in the final set of total codes). As coding categories were straight-forward, discrepancies were not common. When discrepancies did occur, the two coders returned to the qualitative interview transcript to re-examine women’s narratives. In nearly all cases, discrepancies were simple miscodes and did not involve substantive discussions. However, if any new themes emerged during the coding process, these were only added in consultation with the research team. Such consultations did not involve adding larger categories to the analysis, but involved refining more minor subcodes.

Results

Baseline: Sexual initiation, sexual pacing, and sexual decision-making

Sexual initiation

Consistent with traditional sexual scripts, two-thirds of the overall sample at baseline (64% of the experimentals, 73% of the controls) described their ideal encounter as one that included male sexual initiation (see Table 1). Across both the control and experimental arms, women frequently reported that they would “wait for him to do it and just follow their lead,” that they “like the guy to do it” or that they “wouldn’t wanna be the first one making the moves.” Some women who reported male-dominated initiation as most desirable simultaneously described how their own flirtatious actions led the man into the initiation. For example, women explained that, “I would like him to make the first move, but I would like to trick him into thinking he did it,” or that “a little bit of aggression and they’re like … well, they get the hint … “ While 21% of the overall sample revealed a preference for female-dominated initiation, and stated that they preferred to “make the moves,” several of these women reported that they would do so only “if he wasn’t making the first move” or “if I had to.” Only 12% of the overall sample at baseline reported that their ideal script would include a desire for mutual sexual initiation.

Table 1.

Summary of sexual scripts domains: sexual initiation, pacing, decision-making, communication, condom use, and condom timing at baseline and 1 year follow-up

Baseline
 1 Year Follow-Up
Experimentala Controlb Combinedc Experimentala Controlb Combinedc
Variable % (N) % (N) % (N) % (N) % (N) % (N)
Initiation
  Male-dominated 64 (18) 73 (11) 67 (29) 60 (18) 67 (10) 62 (28)
  Female-dominated 25 (7) 13 (2) 21 (9) 30 (9) 20 (3) 27 (12)
  Mutual 11 (3) 13 (2) 12 (5) 10 (3) 13 (2) 11 (5)
Pacing
  Male-dominated 13 (3) 0 (0) 8 (3) 11 (3) 7 (1) 10 (4)
  Female-dominated 63 (15) 58 (7) 61 (22) 68 (19) 64 (9) 67 (28)
  Mutual 25 (6) 42 (5) 31 (11) 21 (6) 29 (4) 24 (10)
Decision-making
  Male-dominated 25 (6) 21 (3) 24 (9) 13 (3) 9 (1) 11 (4)
  Female-dominated 29 (7) 7 (1) 21 (8) 42 (10) 36 (4) 40 (14)
  Mutual 46 (11) 71 (10) 55 (21) 46 (11) 55 (6) 49 (17)
Communication about sexual needs
  Direct 54 (14) 47 (7) 51 (21) 46 (12) 39 (5) 44 (17)
  Indirect 19 (5) 7 (1) 15 (6) 31 (8) 31 (4) 31 (12)
  Both 8 (2) 7 (1) 7 (3) 8 (2) 8 (1) 8 (3)
  No communication 19 (5) 40 (6) 27 (11) 15 (4) 23 (3) 18 (7)
Do condoms ruin sex?
  Yes 10 (3) 7 (1) 9 (4) 7 (2) 0 (0) 5 (2)
  No 90 (26) 93 (13) 91 (39) 93 (27) 100 (14) 95 (41)
Timing of condom introduction
  At the time of penetration 48 (13) 77 (10) 58 (23) 25 (7) 39 (5) 29 (12)
  Right before foreplay begins 15 (4) 8 (1) 13 (5) 29 (8) 15 (2) 24 (10)
  Far before sex begins 26 (7) 15 (2) 23 (9) 25 (7) 23 (3) 24 (10)
  None-automatic by male partner 11 (3) 0 (0) 8 (3) 21 (6) 23 (3) 22 (9)
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Note. Some totals may not add up to the total N due to rounding or missing data.

a

N = 30.

b

N = 15.

c

N = 45.

Sexual pacing

In terms of sexual pacing, more than half of the women in both the control and experimental arms at baseline (63% of experimentals, 58% of controls) stated that women should determine the pace of the sexual encounter. The largest group of women used gendered gatekeeping language to indicate that men would press the sexual pace and that women would then determine how far things would go in the encounter. For example, many women described that “If I didn’t want to go along with it, I would say it, but I would let him bring it up,” or “I’ll tell him to hold on.” Many women also stated that they thought that “he’s not going to want to wait,” indicating that they would “tell him not to take it too far too fast.”

At the same time that many women reported the desire for female-led pacing, 31% of women at baseline (25% of the experimentals, 42% of the controls) reported that both women and men would set the pace mutually in an ideal encounter. Similar to the women who reported female-led pacing, many of the women who described the pace as more mutual indicated that they “won’t let him move too fast… I’d slow it down a little,” or that “if I didn’t feel like doing anything, then I wouldn’t.” It was quite uncommon for women to report that men would need to slow down the sexual pace, but a few women did report themes that indicated that they would “rather have him say how fast things go cause knowing me I would want it to go even faster.”

Sexual decision-making

In terms of who decides what sexual activities the couple would engage in, slightly more than half of the overall sample (55%) conceived mutual sexual decision-making as part of their ideal encounter at baseline (46% of the experimentals, 71% of the controls). For example, women frequently reported that “both parties would take control,” and that “if he can make forceful moves to start, then it’s mutual from there.” Decision-making was described as mutual with the suggestion that once men initiated sex, women would participate more, to “help it along as soon as it got going.” Decision-making was described not only in terms of the act of taking one another’s clothing off, but also during the intimate activities that were carried out afterwards. For example, one woman described that she would like “to do things that please him and have him do things that please me.”

More than one in five women overall (24%) at baseline desired male-led sexual decision-making (25% of the experimentals, 21% of the controls), stating themes such as “he would be more active in suggesting what we would be doing, and well, I would just be cooperative.”

However, nearly as many women at baseline reported a desire for female-led sexual decision-making (21%) as their preference in an ideal scenario (29% of the experimentals, 7% of the controls). Many of these women simply stated that they were more comfortable when they led the sexual decision-making, but a small number of women noted that they would only decide things indirectly so as to “not let him know” that they were actually making such decisions. Using a chi-square test, we found no significant differences at baseline between the control and experimental arms across the domains of sexual initiation, pacing, and decision-making.

Baseline: Communication about sexual needs, do condoms ruin sex?, and timing of condom introductions

Communication about sexual needs

Half of the overall sample at baseline (51%) described an ideal encounter as one in which they directly discussed their sexual wants and needs during sexual intimacy with their male partner (54% of experimentals, 47% of the controls). For example, many women reported themes such as “I ask him to do a particular thing to me or to let me do this to him.” Other women stated that it was necessary to discuss their own sexual wants and needs during sex without hurting men’s feelings. Here, women mentioned that “If I don’t want to do something, I’d tell him… I don’t get upset, but I say this is how I feel… then I try to reassure him.”

The second largest category of women were those who did not imagine themselves talking about sexual needs during sex in an ideal encounter (27%). Many of these women described such talk as “not necessary” since they would indicate their wants and dislikes through body language, such as “showing him” or “encouraging or discouraging him” through touch. A smaller group of women stated that they didn’t talk about their male partner’s wants and dislikes in their ideal scenario, but rather noted that they “figure out what he likes and keep it in my mental Rolodex.” Just under one in five women (15%) overall stated that they did not share wants and needs during sex, but rather that in their ideal sexual scenario, they would use other forms of talk, such as “sexy talk,” during sex. Finally, a few women stated that they would use both direct and indirect tactics to express their wants, most of whom were hoping that they wouldn’t need to talk much in their encounter since it was hoped that their male partner “already knows what to touch or how far to go.”

Do condoms ruin sex?

When asked about whether condoms were part of an ideal sexual encounter or would ruin it, most women (91%) at baseline reported being able to see condoms as part of the ideal encounter (90% of the experimentals, 93% of the controls). In fact, many of these women spontaneously brought condoms up as part of the ideal encounter before they were even asked the specific question about condoms. Even as women imagined condoms in an ideal encounter, several women also described possible resistance to condom use and expressed relief if they didn’t experience conflict. For example, women seemed to hope that there wouldn’t be a conflict around their desire to use a condom, as evidenced by comments such as “and we know that the condom is sitting right over there on the dresser or night stand and that’s already been discussed, so it’s not going to be a big argument. He puts the condom on and that’s all.”

For the women who did not spontaneously bring up condoms in their description of an ideal encounter, they were probed about condoms to see if they could imagine it as a part of the encounter. Here, several women also mentioned male resistance to condom use, and described an ideal scenario as one where men did not resist. For example, when probed on the topic of condom use in an ideal scenario, some reported that “my ideal would be that he would agree—if he didn’t, we wouldn’t [have sex].” Other women who did not mention condoms up front but were probed stated a desire for the “man to already know” that condoms would be used, but noted that it was best not to discuss it, and that it “would just have to be done,” often through her putting the condom on for her male partner.

Not all women saw condoms as part of the ideal encounter at baseline (whether they discussed this spontaneously or when probed). While 91% of the sample thought that condoms would not ruin an ideal sexual encounter, 9% of women reported up front that condoms would certainly ruin the sex. Here, women reported themes such as “the first time is special, I can’t see condoms,” or that “if it’s a fantasy, and a world with no AIDS, then I would probably not use a condom.”

Timing of condom introductions

In terms of the timing of when condoms would be brought up in an ideal encounter, 58% of the sample reported that they would bring up condoms in very close proximity to the time of penile-vaginal penetration (48% of experimentals, 77% of controls). Here, women stated that they would bring condoms up “when we’re hot and heavy,” or “right before the actual act.” The second largest group of women was much smaller and stated that they would bring up condoms far before sexual intimacy even began (23%). These women described talking about condoms with their sexual partner “from the beginning” of the relationship or “weeks in advance” of a sexual encounter “so that you don’t have to stop and explain it.” An even smaller group of women (13%) stated that they would bring condoms up somewhat before clothing was removed, (e.g., at the start of the sexual encounter during kissing). Finally, the smallest group of women (8%) wished that their male partner just put the condom on without being asked at all. Using a chi-square test, we found no significant differences at baseline between the control and experimental arms across the domains of communication about sexual needs, whether women perceived that condoms would ruin sex, or the timing of condom introductions.

One year follow-up: Sexual initiation, sexual pacing, and sexual decision-making

Sexual initiation

At one year follow-up, similar to baseline, most women (62%) described a preference for male-led sexual initiation as part of an ideal sexual scenario (see Table 1). Both the experimental and control arms showed small overall decreases in the desire for male sexual initiation (64% vs. 60% for experimentals, 73% vs. 67% for controls). There was no change from baseline to follow-up across the study arms concerning the percentage of women who desired mutual sexual initiation. At the same time, both the experimental and control arms showed modest increases in the percentage of women who desired female-sexual initiation at follow-up (25% vs. 30% for experimentals, 13% vs. 20% for controls). Thus, overall, there was some shift in both the experimental and control arms from baseline to one year follow-up in the direction of moving from a traditional script of male sexual initiation to a more female-dominated one. Women who described a female-dominated initiation script at one year follow-up mentioned themes that indicated that they would “rather make the first move” either by kissing, touching, nibbling on, licking, or massaging their partner. Some women reported “surprising” their male partner through sexual initiation that involved some combination of lingerie, kissing, and touching.

Sexual pacing

Overall, similar to baseline, at the one year follow-up assessment most women viewed female-led pacing as ideal (67%), with 24% of the sample reporting that mutual led pacing was ideal and 10% of the sample reporting that male led pacing was ideal. Both the experimental and control arms showed small decreases in the percentage of women who shifted in their ideal script from mutual pacing (25% vs. 21% for experimentals, 42% vs. 29% for controls) towards a desire for female-controlled sexual pacing (63% vs. 68% for experimentals, 58% vs. 64% for controls). Themes on female-dominated pacing were similar across the intervention arms, where women noted that “I would decide how fast or slow things would go.” For those women with children, they noted that pacing was more likely to be controlled by them since “if I invited him to my house, I have to watch out for the children, they could be home, and everything would revolve around that.”

Sexual decision-making

Similar to the overall pattern at baseline, 49% of women desired mutual sexual decision-making at one year follow-up. However, nearly as many women reported at one year follow-up that they preferred female-dominated sexual decision-making (40%). Overall, there was a substantial decrease at one year follow-up in the desire for male sexual decision-making from baseline (24%) to one year follow-up (11%). In terms of changes by group, there was a decrease in the experimental arm in male sexual decision-making, (25% at baseline vs. 13% at follow-up) and also among the controls (21% at baseline vs. 9% at follow-up), although the trend was in the same direction. Simultaneously, both the experimental and control arms showed increases in the percentage of women who stated a desire for female-dominated sexual decision making at follow-up (29% vs. 42% for experimentals, 7% at baseline vs. 36% for controls). Characterizing the overall tone of this change, many women stated themes indicating a strong desire for their own sexual decision-making such as “I would take the lead, I would have to say it would be me,” or “his role is to do what I want, so I have the decision-making.”

One-year follow-up: Communication about sexual needs, do condoms ruin sex?, and timing of condom introductions

Communication about sexual needs

At baseline, 51% of women felt that they could directly state their sexual needs with male partners, and at one year follow-up 44% of women stated the same. While nearly one in three women at baseline stated that they wouldn’t need to talk about sexual needs during the encounter, under one in five stated this theme at follow-up. At one year follow-up, the smallest category overall remained those women who reported using both direct and indirect body language. In terms of change, both the experimental and control arms revealed increases in the percentage of women who reported using indirect communication tactics at one year followup (19% vs. 31% of experimentals, 7% vs. 31% of controls) and small decreases in direct communication (54% vs. 46% of experimentals, 47% vs. 39% of controls). Both the experimental and control arms also revealed decreases in the percentage of women who reported using no communication about their sexual needs during sex at one year follow-up (19% vs. 15% of the experimentals, 40% vs. 23% of the controls).

Do condoms ruin sex?, and timing of condom introductions

Similar to baseline, nearly all women (95%) at the one year follow-up felt that condoms would not ruin an ideal sexual scenario, and a very small percentage of women (5%) felt that condoms would ruin sex. In terms of the timing of condom introductions, 58% of women at baseline reported that condoms would be brought up at the time of penetration. At one year followup, only 29% of women stated this theme, with both the control and experimental arms departing from an imagined tendency to bring condoms up very close to the time of penetration. Both the control and experimental arms reported increases in the percentage of women who would bring condoms up at an earlier point in the sexual scenario rather than right before penetration. Here, women indicated that they would bring up condoms before sexual intimacy began, and reported themes such as:

If I knew we were going to have sex I think that, especially now after going through all this, I try to bring up the condom earlier because I think that would almost make it, kind of get it out of the way because it’s gonna be in the back of your mind anyway through this whole scenario… my conscience is going to be eating away at me…

Finally, only 8% of women at baseline reported that they wished that men would put on a condom themselves without having to raise the issue or ask them to do so. At one year follow-up, this percentage increased among both the control and experimental arms to more than 1 in 5 women. Here, women in both intervention arms discussed themes such as: “I hope I don’t have to discuss it, that he already knows that he has to use a condom… for him to just show me that I don’t have to tell him to put on a condom… he’s just going to put it on.”

Discussion

Project FIO was an HIV prevention intervention that sought to reduce sexual risks by combining social psychological and gender-specific strategies. The gender-specific exercises for the intervention groups emphasized choosing the right partner, assertive safer sex negotiations, sexual and bodily rights, women’s sexual pleasure, women’s agency and choice, and challenges to traditional gender scripts. The goal of the present study was to describe sexual scripts at baseline and examine changes in women’s sexual scripts at one year follow-up for a randomly selected subsample of women who participated in project FIO. In this qualitative study, we sought to examine whether changes in sexual scripts occurred across study arms and, if so, to assess if such changes were different across experimental and control arms, holding possible implications for safer sex practices.

Examination of whether and how traditional scripts are modified and changed through intervention sessions is particularly crucial as researchers have become increasingly adept at understanding the ways in which overconformity to traditional gender norms may exacerbate HIV risk. This risk occurs not only through gender-based power imbalances, but through larger cultural norms that encourage passivity in women during sexual initiation and decision-making, by encouraging women to place the centrality of male pleasure at the center of sexual scenarios at the expense of safer sex needs, and by encouraging women to leave condom initiation and use to men. For men, traditional scripts place pressure on men to be the “knower” and “doer” in sex, and to engage in any and all sexual activity at all costs—activity that might ultimately hold high risk for HIV infection or transmission (Campbell, 1995).

Few have empirically examined whether sexual scripts can be intervened upon and how scripts might change over time as part of the goals of a risk reduction trial. At baseline and follow-up, the overall trends in this subsample of participants were similar in the domains of sexual initiation, pacing, and sexual decision-making. At both time points, most women described male sexual initiation, female-led pace keeping, and mutual sexual decision-making as an ideal sexual script, as is often the case in traditional scripts. At one year follow-up, there was some movement away from male-dominated and towards female-led sexual initiation and pacing, with changes occurring evenly in both the control and experimental arms. In terms of communication about sexual needs, women were most likely to report at baseline that they used direct communication with male partners. At one year follow-up, there was some shift away from a description of no communication or direct communication about sexual needs and a tendency to imagine carrying out more indirect communication among both the experimental and control arms.

Other noteworthy qualitative changes occurred in terms of the timing of condom introductions. At baseline, most women imagined condoms as part of their ideal scenario, and many imagined that they would bring up the subject right before penile-vaginal penetration began. When assessed at one year follow-up, a smaller proportion of women in both arms described bringing up condoms at that stage of their ideal scenario. Overall, women at one year follow-up in both arms were just as likely to report that the timing of their condom introductions would be before sexual intimacy began. One in five women at follow-up imagined not having to bring condoms up at all since they hoped that male partners would “just know that he should wear one” and would therefore put a condom on without being asked. While we cannot be certain as to why women were more likely to report this at one year followup, this may indicate a desire to not interrupt the moment, fatigue with making condom requests to male partners, or a wish that resistance to condom use would be minimized. These findings are important to track in future research given larger trends that show that men are not as resistant to the refusal of sex so much as to the timing of requests for condom use, where waiting until the last minute is more likely to elicit a negative response (Rivers & Aggleton, 1999).

Finally, findings concerning a move towards female-dominated sexual decision-making and an earlier timing of condom introductions were particularly noteworthy, as previous researchers have found that sexual communication is vital during the formation of a relationship, given that it is much more difficult to introduce condoms once one is already in an established relationship (Misovich, Fisher, & Fisher, 1997). Whether there is, in fact, a relationship between conceiving of an earlier condom introduction or female-dominated sexual decision-making (e.g., imagining these in an ideal sexual script) at the intrapsychic level and enacting these practices in actual sexual scenarios is an empirical question that should be further elaborated. Intervening on scripts could certainly assist in structuring an intention in intervention trials, which is often a strong predictor of actual behavior (Fishbein et al., 2001).

The fact that so many of the trends and changes were similar in the control and experimental arms reinforces our previous quantitative findings that control group participants do, in fact, change in randomized trials (Ehrhardt, Exner, Hoffman, Silberman, & Yingling, et al., 2002; Ehrhardt, Exner, Hoffman, Silberman, Leu, et al., 2002). The same held true in a previous post-trial qualitative analysis from this trial (Dworkin, Exner, Melendez, Hoffman, & Ehrhardt, 2006). These results may be reflective of longstanding debates about placebo effects in control groups within clinical trials (Djulbegovic, 2001, Newman, Browner, Cummings, & Hulley 2001; Parsons, 1974), and shed light on the specifics of how and why control groups change. We do not hypothesize that the changes in the control group were “placebo effects,” but rather likely reflect the degree to which a lengthy assessment of psychosexual factors, sexual pleasure, and sexual functioning facilitates comfort with discussing and perhaps imagining or enacting new sexual behaviors.

Previous researchers have not necessarily delineated separate elements of the sexual script when making the claim that “traditional sexual scripts” shape women’s and men’s HIV risks in heterosexual relationships. The question remains as to what elements of the script HIV/AIDS researchers should focus on when considering the multiple elements involved in a script. That is, it is not clear whether female sexual initiation, pacing, sexual decision-making, communication about sexual needs, or the timing of condom introductions are the crucial domains (or if some combination of these, or all of these need to change) to consider when attempting to affect behavioral changes concerning safer sex.

Simultaneously, it is necessary to understand how both women and men perceive their own and their partner’s sexual scripts in order to best influence dyadic sexual decision-making, communication, and safer sex negotiations (Seal & Ehrhardt, 2003). Indeed, our analysis was based on a report from one member of the couple without understanding what the other member of the couple finds ideal. Examining gender relationally is important for researchers to consider when strategizing on how to intervene on gender scripts as part of HIV/AIDS prevention interventions, particularly if there are implications for safer sex in the divergence or convergence of men’s and women’s desires (currently and over time).

Furthermore, even as scripts are increasingly examined within HIV/AIDS research, it is not common to note the level of analysis in sexual scripts work. The level of analysis is vital to delineate and consider (intraspychic, interpersonal, cultural). Currently, the cultural realm of sexual scripts is studied more commonly than either interpersonal or in-trapsychic scripts (Dworkin & O’Sullivan, 2005; Whittier & Melendez, 2004). In this particular intervention, questions about scripts were written to be centrally focused on the intrapsychic realm, which was defined as the motivational elements that produce commitments to a particular action sequence, including desires and fantasies. While the intraspsychic realm was our emphasis, it is difficult to predict how women would have responded to questions about the other two levels of sexual scripts. As this was the first gender-specific HIV/AIDS prevention trial that has included an exploratory qualitative component to examine sexual scripts, our work is only a beginning in highlighting multiple, specific domains of the sexual script, and in underscoring one level of analysis (intrapsychic) of several that can be examined. Future research should ensure that clear operationalizations are provided for multiple domains of the script (pace, initiation, decision-making, etc.), and for the different levels of scripts analysis (interpersonal, intrapsychic, cultural).

Since this small qualitative study was not powered to quantitatively discern whether there were statistically significant differences over time on scripts domains, nor was it powered to examine whether or not and how changes in sexual scripts might affect sexual risk behavior, we have not elaborated on these issues here. It is also vital for future research that hypothetical and actual sexual scripts (what one might do versus what one actually does) are explored in tandem.

While the small number of women in each racial/ethnic category did not allow for valid comparisons in this analysis, future research might also consider not only gendered aspects of scripts but also racialized and classed aspects of scripts. Indeed, race or class status might intersect with gender in ways that uniquely shape sexual scripts and this possibility should certainly be further explored in future studies (Collins, 1990; Mahay et al., 2001). Finally, some of the women did exhibit same-sex behaviors, and the research team did collect information on these behaviors. However, we did not collect sexual scripts information on same-sex behaviors as we were centrally concerned with intervening on the gendered contexts that shape risk in heterosexual relationships. How sexual scripts differ by sexual orientation or across different partners is also clearly an important and promising area for future studies that emphasize the intersection of HIV/AIDS risks and sexual scripts.

Within HIV prevention work that is directed at heterosexual women, it is generally understood that theoretically-driven interventions that are tailored to the unique circumstances of the target population, have sustained contact with participants, offer the opportunity to practice skills, and are embedded in the context of women’s relationships offer an effective means to changing risky sexual behaviors (Amaro, 1995; Amaro & Raj, 2000; Blanc, 2001; Ehrhardt, Yingling, Zawadski, & Martinez-Ramirez, 1992; Ehrhardt & Exner, 2000; Exner, Gardos, Seal, & Ehrhardt, 1997; Exner et al., 2003; Logan et al., 2002; Wingood & DiClemente, 2000). Scripts are one window into relationships and into the contexts that structure (and are structured by) heterosexual interactions. Research that further operationalizes domains in sexual scripts and links these to actual behavior may offer a unique contribution to the next generation of HIV/AIDS prevention intervention trials that are focused on changing gendered contexts and gendered power.

Acknowledgments

This research was supported by center grants P50-MH43520 and P30-MH43520 from NIMH to the HIV Center for Clinical and Behavioral Studies, Anke A. Ehrhardt, Ph.D., Principal Investigator, and by NRSA training grant T32-MH19139, to Behavioral Sciences Research in HIV Infection. The opinions expressed in this paper do not necessarily reflect those of Planned Parenthood Federation of America, Inc. We thank the study participants for their involvement. The authors gratefully acknowledge comments provided by the Editor and anonymous reviewers. We are also grateful to Susie Hoffman, Theresa Exner, Cheng-Shiun Leu, Mike Stirratt, post-doctoral research fellows at the HIV Center, and the careful editing and assistance provided by Vanessa Haney, Iymaani Aytes, Myra Garcia, and Pat Warne.

Contributor Information

Shari L. Dworkin, Email: sld2011@columbia.edu, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, New York; Department of Psychiatry, Columbia University, New York, New York; HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit #15, New York, New York 10032.

Sharlene T. Beckford, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, New York

Anke A. Ehrhardt, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, New York Department of Psychiatry, Columbia University, New York, New York.

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