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Abstract

Researchers have identified engagement in sexual concurrency, particularly when condom use is inconsistent, as a risk factor for HIV and other sexually transmitted infections. This risk is particularly salient in rural communities in which dense interconnection of sexual networks can promote the spread of sexually transmitted infections. The authors investigated individual and relationship factors that predict inconsistent condom use in the context of main and casual partner sexual concurrency among 176 rural African American men. The individual psychosocial factors investigated included impulsivity and anger/hostility. Relationship variables included fidelity expectations, criticism from partners, and relationship control in both main and casual relationships. No individual risk factors were associated with main partner inconsistent condom use; however, impulsivity and anger/hostility positively predicted inconsistent condom use with a casual partner. Relationship control in the main partnership predicted inconsistent condom use with the main partner. Criticism from the main partner positively predicted inconsistent condom use with a casual partner. Finally, expectations for a casual partner’s fidelity positively predicted inconsistent condom use with that partner. These findings underscore the importance of considering the influence of one sexual partnership on behavior in another and of taking this complexity into account in the development of preventive interventions.

Keywords

African American men HIV inconsistent condom use casual partner concurrency

Introduction

Nationally, rates of HIV among African American men who have sex with women (hereafter called heterosexual men) in both rural and urban areas are nearly 10 times as high as those reported for heterosexual Caucasian men (McCree, 2009). High rates of HIV are particularly evident in small towns and rural communities in the southern United States (Hall, Li, & McKenna, 2005). The South accounts for more than one third of all AIDS cases in the United States, and infection among residents of rural areas is more likely to occur in the South than in other areas of the country (Reif, Geonnotti, & Whetten, 2006). Although HIV is more prevalent among heterosexual African American women than men, heterosexual transmission is facilitated by high rates of sexually transmitted infections (STIs) other than HIV, both inflammatory and ulcerative, which increase HIV infectivity and susceptibility in both women and men (Fleming & Wasserheit, 1999). Risk conferred by STIs acquired in heterosexual relationships increases the potential for HIV to spread throughout a population.

Engaging in concurrent sexual partnerships (sexual relationships that overlap across time) has been identified as a prominent risk factor for HIV and other STIs (Adimora et al., 2004; Adimora, Schoenbach, & Doherty, 2006; Morris, Kurth, Hamilton, Moody, & Wakefield, 2009). Concurrency may pose an even greater risk for African Americans in small towns and rural communities. In these communities, a restricted dating pool and interconnected sexual networks increases the potential for sexually transmitted pathogens to spread through a community (Adimora et al., 2004). Recent research indicates that, for some rural African American young men, sexual concurrency assumes a pattern that includes a “main,” primary partner along with one or more casual sexual partners (Adimora et al., 2001; Kogan et al., 2010; Senn, Carey, Vanable, Coury-Doniger, & Urban, 2009; Willis & Clark, 2009). In a recent study of rural African American young men, of those who reported being in a committed relationship, 46% also reported ongoing sexual relationships with one or more casual partners. Studies reveal that condom use tends to be more consistent with casual partners and less consistent with primary partners (Carey, Senn, Seward, & Vanable, 2010; Frye et al., 2013). A substantial number of men, however, do not use condoms consistently with casual partners; this poses uniquely high risks for STI transmission to their partners and themselves.

Although studies have examined the correlates of condom use with partners designated as primary or casual (Adimora et al., 2004; Adimora et al., 2006), no research has addressed the complexity of condom use among men who report two or more ongoing partners. In these situations, men’s sexual activity and decisions regarding condom use occur within a complex system of relationships. Characteristics of each relationship, as well as men’s personal attitudes, conceivably can influence their decisions about using condoms consistently with particular sexual partners. In this kind of relationship context, condom use predictors may vary with different types of partners.

The individual psychosocial factors investigated include impulsivity and anger/hostility. Impulsivity and anger/hostility are both externalizing behaviors that are related sexual risk behaviors. Impulsivity has been implicated in a range of sexual risk behaviors, including inconsistent condom use, casual sex, sexual relations with concurrent partners, and sex while intoxicated (Devieux et al., 2002; Donohew et al., 2000; Hoyle, Fejfar, & Miller, 2000; Pack, Crosby, & St. Lawrence, 2001; Robbins & Bryan, 2004). Studies suggest that impulsive individuals may lack the self-regulatory capacity needed to resist hedonistic impulses when opportunities for unprotected sexual activity arise (Hoyle et al., 2000). Emotion regulation difficulties evinced by elevated levels of anger and hostility are associated with a wide range of maladaptive behaviors, including substance use (Bonn-Miller, Vujanovic, & Zvolensky, 2008) and risky sexual behavior (Messman-Moore, Walsh, & DiLillo, 2010; Tull, Weiss, Adams, & Gratz, 2012). Evidence suggests that high arousal negative affect such as anger may influence recognition of risk and the ability or motivation to foresee the consequences of one’s actions (Crepaz & Marks, 2001). People who feel hostility also may be unconcerned about their own and others’ well-being, leading to reduced motivation to avoid acquiring and transmitting STI/HIV infections (Crepaz & Marks, 2001).

Relationship Factors

Recent research underscores the importance of the relationship context in decision making regarding condom use and a range of relationship-related characteristics and interpersonal processes have been linked to condom use behavior (Fehr, Vidourek, & King, 2015; Frye et al., 2013; Manning, Flanigan, Giordano, & Longmore, 2009). Few if any studies, however, have examined the influence of relationship processes among men engaging simultaneously in two or more ongoing sexual relationships. The present study examines the influence of fidelity expectations, criticism from partners, and control in these relationships.

Fidelity expectations refer to a partner’s beliefs about relationship exclusivity (Eyre, Flythe, Hoffman, & Fraser, 2012), which affects partners’ motivation to use condoms (Baumgartner, Lugina, Johnson, & Nyamhanga, 2010). High levels of criticism from a partner are hypothesized to affect condom use decisions. Such negative relationships dynamics have been associated with inconsistent condom use in dating relationships (Manning et al., 2009). It is plausible that, when a man perceives his partner to be critical or hostile, concern for that partner’s sexual health may be undermined by feelings of anger.

Past research with women documents the risks associated with imbalances in relationship control. Specifically, when men evince high levels of dominating and controlling behavior, women’s risk for STIs increases (Crosby et al., 2000; DiClemente et al., 2008). When men have disproportionately high relationship power, they tend to make condom use decisions for both themselves and their intimate partners; such men often exhibit less motivation for condom use than do their partners (Fehr et al., 2015). Results are mixed, however, with some studies finding links to condom use and others finding no association (Teitelman, Ratcliffe, Morales-Aleman, & Sullivan, 2008). Little or no research has explored sexual relationship power from the perspective of young African American men who are in concurrent sexual relationships.

In summary, the present study addresses the personal and relationship factors that predict condom use among a sample of 176 young African American men living in rural environments who report ongoing relationships with both a main partner and a casual partner. The authors collected data on condom use with both main and causal partners and on characteristics of both relationships, allowing the examination of decision making about condom use in a complex context of concurrency. The authors examined the extent to which impulsivity and anger/hostility predicted inconsistent condom use with each type of partner, in addition to the influence of fidelity expectations, criticism, and sexual relationship power.

Method

Participants

Participants were 505 African American men, 19 to 22 years of age, who were enrolled in the African American Men’s Health Project. Men were recruited from 11 counties in rural Georgia. These communities are representative of the southern Coastal Plain, a geographic concentration of rural poverty that coincides with the nation’s worst economic and health disparities by race, including HIV infections (Wimberley & Morris, 2002). Of the 505 participants, 367 reported being in a committed relationship with a “main” female sexual partner, defined as “a woman or girl that you have a very special or committed relationship with, such as a girlfriend or a spouse.” Of the men with a main partner, 176 (48%) reported having one or more casual sexual partners in the past 3 months. The present study focuses on these 176 men who reported having both a main partner and a casual partner, “someone you’ve had sex with only once, or a few times, or you have sex with them on an ongoing, casual basis.”

Procedures

Participants were recruited using respondent-driven sampling (Heckathorn, 1997), which is a referral-based recruitment method that alleviates the bias inherent in typical snowball sampling methods. Respondent-driven sampling is a preferred method for sampling interconnected but hard-to-reach populations, for example, African American young men who change residences often. Community Liaisons (CLs) in the counties of interest recruited 45 initial participants, known as “seeds,” across the 11 counties to complete the survey. Surveys were completed by participants in their homes or a convenient location in the community. On completion, participants were asked to give the names of three other men they knew other than their brother or close kin with whom they grew up in the same home. The project staff contacted the referred participants, and on meeting eligibility requirements, the referring participant would receive $25 per person who they referred into the study. Once the referred participants completed the survey, they were asked to refer three more men in their network. Participants completed the survey on a laptop computer using an audio computer-assisted self-interview. This allowed participants to navigate the survey with the help of voice and video enhancements. Participants received $100 for completing the survey. Informed consent was obtained from all participants following a protocol that was approved by the institutional review board at the University of Georgia.

Measures

Main and Casual Partner Condom Use

Participants were first queried regarding the frequency of vaginal intercourse with each of their partners. Condom use was assessed with a follow-up item on which men reported the frequency of condom use with each partner on a scale ranging from 1 (never) to 5 (always). Participants who indicated they always used condoms were assigned a 0, indicating consistent condom use. Participants who indicated they used condoms less frequently than always were assigned a 1, indicating inconsistent condom use.

Individual Psychosocial Factors

Impulsivity was assessed with the Lack of Premeditation subscale of the Impulsive Behavior Scale (Whiteside & Lynam, 2001). The measure was adapted for this study on the basis of participant feedback. Some items were deleted to shorten the questionnaire, and some items were reworded for clarity (Kogan, Cho, Barnum, & Brown, 2015). The resulting revised subscale had four items and a response set ranging from 1 (strongly disagree) to 4 (strongly agree). Example items include “I like to stop and think about things before doing them” and “Before making up my mind, I consider all the advantages and disadvantages.” Cronbach’s alpha was .67. Premeditation items were recoded so that higher scores reflected a greater lack of premeditation. Hostility/anger were assessed using an eight-item measure from the Client Evaluation of Self and Treatment (Joe, Broome, Rowan-Szal, & Simpson, 2002). Example items include “You feel a lot of anger inside of you” and “You have urges to fight or hurt others.” The response scale ranged from 1 (strongly disagree) to 4 (strongly agree). Cronbach’s alpha for this measure was .87.

Relationship Factors

Fidelity expectations were assessed using the mean of the scores on two items developed for this study: “My partner expects me to have sex only with her” and “I expect my partner to have sex only with me.” These items were rated on a 4-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree). Cronbach’s alphas for this measure were .75 (main partner) and .79 (casual partner). Criticism was assessed with a three-item subscale from the Network of Relationships Inventory (Furman & Buhrmester, 1985). The response scale ranged from 0 (never) to 3 (very often). An example item was “How often does she point out your faults or put you down?” Cronbach’s alphas for this measure were .68 (main partner) and .81 (casual partner). Relationship control was evaluated with items from the Sexual Relationship Power Measure (SRPM; Pulerwitz, Gortmaker, & DeJong, 2000). The SRPM was originally developed with female participants and focuses on behaviors by a partner in the relationship toward the participant (e.g., “My partner tells me who I can spend time with”). The authors adapted the items to address the same dynamics in terms of the participant initiating the behavior (e.g., “I tell my partner who she can spend time with”). The relationship control subscale included six items indexing overt controlling behavior by the participant in the relationship (e.g., “I always want to know where my partner is,” “I will not let my partner wear certain things”). Participants responded on a scale ranging from 1 (strongly disagree) to 4 (strongly agree). Cronbach’s alphas for the scale were .68 (main partner) and .77 (casual partner).

Control Variable

Other birth control with the main partner was assessed with a checklist. Participants were asked, “Does your main partner use any of these kinds of birth control?” Example items included birth control pills, birth control shots, implants, patches, or an intrauterine device. Participants who indicated that their partners used any birth control other than condoms were assigned a 1; those who did not report the use of other birth control were assigned a 0.

Data Analysis

Statistical analyses were conducted with the Statistical Package for the Social Sciences (SPSS, version 22). Paired-sample t tests were conducted to compare relationship variables between main and casual partners. The authors then examined adjusted associations of each predictor with main and casual partner condom use using logistic regression. In the main partner condom use models, the authors adjusted for casual partner condom use and use of other birth control with the main partner. In predicting casual partner condom use, we adjusted for main partner condom use and other birth control with the main partner.

Results

Descriptive statistics for study variables, including comparisons of relationship characteristics for main and casual partnerships, are presented in Table 1. On average, the men were 20 years old and most (74%) had completed high school or obtained a GED. Their average total monthly income was $759.78. On average, the young men had sex with four different women close in age to themselves within the past 3 months. More than half of the men (60%) also reported that, within the past 3 months, they “sometimes” had sex after using alcohol or other drugs, 20% reported “never” using substances before having sex, and 20% reported using substances “often” or “almost every time” before having sex. Inconsistent condom use was significantly more common in main partnerships than in casual partnerships. With regard to main partners, 84% of the men reported inconsistent condom use; regarding casual partners, 49% of the men reported inconsistent condom use. Main and casual partnerships differed significantly across all relationship characteristics. Compared with casual partnerships, main partnerships were characterized by higher fidelity expectations, criticism from the female partner, and relationship control on the part of the male partner.

Table 1.

Descriptive Statistics and t-Test Results for Relationship Variables.

Outcome	M	SD	Main partner		Casual partner		t
Outcome	M	SD	M	SD	M	SD	t
Age	20.32	1.23
Income	759.78	644.16
Education	4.27	1.34
Inconsistent condom use			0.84	0.37	0.49	0.47	−9.72***
Individual risk factors
Lack of premeditation	3.25	0.52
Anger/hostility	2.44	0.65
Relationship factors
Criticism from partner			0.87	0.68	0.50	0.62	5.61***
Fidelity expectations			3.61	0.62	2.41	0.89	16.19***
Relationship control			2.35	0.58	2.02	0.64	7.04***
Control
Other birth control (main only)			0.86	0.34

***

p < .001.

Table 2 presents adjusted associations of each study variable with main and casual partner condom use. No individual risk factors were associated significantly with main partner condom use inconsistency. Individual risk factors that were significantly associated with casual partner condom use inconsistency included impulsivity (odds ratio [OR] = 1.41, p = .00) and anger/hostility (OR = 1.10, p = .04). Main partnership relationship control was associated with inconsistent condom use with the main partner (OR = 2.89, p = .04). Criticism from the main partner was significantly associated with casual partner condom use inconsistency (OR = 2.44, p = .00). Finally, fidelity expectations in the relationship with the casual partner were significantly associated with casual partner condom use inconsistency (OR = 1.76, p = .02).

Table 2.

Adjusted Associations of Inconsistent Condom Use With Study Variables.

	Main partner, OR (95% CI)	Casual partner, OR (95% CI)
Lack of premeditation	1.07 (−0.21, 0.35)	1.41*** (0.12, 0.56)
Anger/hostility	1.08 (−0.03, 0.18)	1.10* (0.00, 0.18)
Main partner relationship variables
Fidelity expectations	1.95 (−0.07, 1.39)	0.96 (−0.68, 0.59)
Criticism from partner	1.05 (−0.82, 0.92)	2.44*** (0.28, 1.51)
Relationship control	2.89* (0.04, 2.04)	1.26 (−0.52, 0.99)
Casual partner relationship variables
Fidelity expectations	0.81 (−0.84, 0.41)	1.76* (0.08, 1.04)
Criticism from partner	0.81 (−1.07, 0.65)	1.13 (−0.54, 0.79)
Relationship control	0.36 (−2.13, 0.10)	0.83 (−1.04, 0.67)

Note. 1 = inconsistent condom use; 0 = consistent condom use; OR = odds ratio; CI = confidence interval. Main partner’s use of other birth control was included in all logistic regression models. In predicting condom use with main partners, casual partner condom use also was controlled. In predicting condom use with casual partners, main partner condom use also was controlled.

p < .05. ***p < .001.

Discussion

Current research indicates that sexual concurrency and inconsistent condom use are major risk factors for STIs, including HIV, in rural African American communities (Adimora et al., 2004; Adimora et al., 2006; Morris et al., 2009). The present study investigated predictors of condom use among a sample of African American young men who are in ongoing, concurrent sexual relationships. Study findings suggest that the factors associated with inconsistent condom use differ in main and casual partnerships. Control in the relationship with the main partner was the only predictor of main partner condom use inconsistency. Predictors of condom use inconsistency in the casual partner relationship included men’s impulsivity and anger/hostility, criticism in the main partner relationship, and fidelity expectations in the casual partner relationship.

Past research has linked a range of individual psychosocial factors to condom use, including aspects of impulsivity and anger (Hoyle et al., 2000). Interestingly, when condom use with a casual partner and use of other birth control by the main partner were controlled, neither impulsivity nor anger predicted inconsistent condom use with main partners. These psychosocial factors did, however, predict inconsistent condom use with a casual partner. This suggests that impulsivity and anger may have a more prominent role in sexual safety in casual versus main partnerships among men in concurrent relationships. Men’s sexual activity may be more regulated within the context of a main partnership that in a casual partnership (Manning et al., 2009). Young men in main partnerships likely participate in more routinized, ongoing negotiations and adjustments regarding sexual behavior as part of a more stable relationship. Such routine behavior is hypothesized to counter tendencies to act on impulse. In contrast, young men may feel less motivated to engage in negotiation or regulate their behavior and emotions within casual partnerships. This conjecture is consistent with past research indicating that men who engage in casual sexual partnerships may view their behavior as a way of demonstrating their sexual prowess; they may also use their casual relationships to provide immediate gratification for their sexual desires (Regan & Dreyer, 1999). Because casual partnerships may entail lower incentives for self- and emotion regulation, anger and a lack of premeditation may be particularly influential on decisions about condom use in this context.

Relationship factors have been identified as important predictors of condom use (Manlove, Ryan, & Franzetta, 2003). Consistent with these findings, the present study documented associations between casual partner fidelity expectations and inconsistent condom use in casual partnerships. Past research indicates that men increase condom use when they do not trust a partner to be faithful in a relationship (Fehr et al., 2015). Conversely, as couples become more intimate and their expectations for exclusivity increase, other forms of birth control are often used that are considered to enhance intimacy as the protection from STIs that condoms provide becomes less salient (Manlove et al., 2003).

Relationship control involves men’s dominating and controlling behaviors in their relationships. In the main partnership, relationship control predicted inconsistent condom use with the main partner. This is consistent with studies indicating that, when men have greater decision-making power, they often choose to forego condom use (Manning et al., 2009; Tschann, Adler, Millstein, Gurvey, & Ellen, 2002).

The investigation of simultaneous relationships permitted the examination of the ways in which characteristics of one relationship can predict condom use in another. Interestingly, criticism from the main partner emerged as a predictor of inconsistent condom use with the casual partner. It is possible that men’s concerns for their main partners’ sexual health may be diminished by criticism from the main partner; this may give men a feeling of “permission” to have unprotected sex in their casual relationships. Similarly, as noted previously, men may engage in casual partnerships to affirm their masculine prowess and seek immediate gratification. Perhaps receiving criticism from his main partner may enhance a man’s desire to affirm his masculinity through risky sexual behaviors with casual partners.

Several limitations in the present study should be noted. Participants were from resource-poor rural environments; thus, the generalizability of the findings to urban men is not known. The study results depend on reports about dynamics in two relationships; additional research that includes data from partners would be valuable. Investigating other key variables related to sexual behavior, such as length of relationships, relationship quality, or acceptability of condoms, could also inform condom use behavior. Finally, several of the scales displayed modest internal consistencies, increasing the potential for Type 1 errors. These limitations notwithstanding, the present research advances knowledge of HIV risk and prevention with a novel sample: men who report both main and ongoing casual partnerships.

Conclusions

To date, little research has examined psychosocial and relationship factors that influence inconsistent condom use across two sexually concurrent relationships. Study findings suggest that a portion of African American young men have dynamic systems of sexual relationships and that behaviors in one relationship may affect behaviors in the other relationship. Current interventions, however, rarely address the potential for specific risk factors to have different effects depending on the sexual relationship that is under consideration. Intervention developers may need to consider targeting relationships dynamics within specific partnerships to reduce more effectively risk for STIs and reduce the rates of HIV transmission in this population.

Footnotes

Authors’ Note

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health, the funding agency.

The authors will make anonymous data pertinent to this analysis available for scientific use for qualified users. Data will be made available under a data-sharing agreement that requires commitments to (a) using the data only for research purposes and not to identify any individual participant, (b) securing the data using appropriate computer technology, and (c) destroying or returning the data after analyses are completed.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by Award Number R01 DA029488 from the National Institute on Drug Abuse. This study was also supported, in part, by the Surgeon General C. Everett Koop HIV/AIDS Research Grant from the Rural Center for AIDS/STD Prevention, Indiana University School of Public Health-Bloomington.

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Condom Use in the Context of Main and Casual Partner Concurrency: Individual and Relationship Predictors in a Sample of Heterosexual African American Men

Abstract

Keywords

Introduction

Relationship Factors

Method

Participants

Procedures

Measures

Main and Casual Partner Condom Use

Individual Psychosocial Factors

Relationship Factors

Control Variable

Data Analysis

Results

Discussion

Conclusions

Footnotes

Authors’ Note

Declaration of Conflicting Interests

Funding

References