Body Image and HIV Risk among College Students Meghan M. Gillen, PhD; Charlotte N. Markey, PhD Objectives: To focus on the role of sex, race/ethnicity, and body image in HIVprotective behaviors. Methods: Undergraduates (N = 277; 53% women; M = 19.27 years old) from the United States completed a survey on HIV-related behaviors and body image (appearance orientation and appearance evaluation). Results: Women and African Americans/ Blacks were more likely to have ever had an HIV test. African Americans/Blacks and individuals who had more positive evaluations of their appearance were
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ollege students engage in high rates of risky sexual behavior,1-3 thereby increasing their risk for acquiring sexually transmitted infections (STIs). HIV (human immunodeficiency virus) is a particularly serious STI as it can lead to health complications and death.4,5 Approximately 1.1 million people in the United States have HIV, with African Americans and young people ages 13 – 24 being disproportionately affected.4 However, some people who are infected with HIV may be unaware of their HIV status. In fact, as many as 16% of people who have the virus do not know they have it.4 Obtaining an HIV test, which is recommended as part of routine healthcare for adolescents and adults, is the only effective means of knowing one’s status and may help reduce the spread of infection by shaping one’s own as well as one’s partner’s sexual choices.6,7 Communicating with a partner about one’s HIV status also may be important in determining people’s future sexual behavior. In fact, the Centers for Disease Control and Prevention (CDC)7 recommends that medical practitioners communicate to their patients that both them and their potential future partners should get tested before engaging in sexual behavior. The goal of the current study was to examine how sex, race/ethnicity, and body image may be related to Meghan M. Gillen, Assistant Professor, Pennsylvania State University, Division of Social Sciences, Abington, PA. Charlotte N. Markey, Associate Professor, Rutgers University, Department of Psychology, Camden, NJ. Correspondence Dr Gillen; [email protected]
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more likely to have ever asked a partner’s HIV status and to have asked a partner to get tested for HIV. Conclusions: Findings indicate low rates of HIV testing and communication with a partner about HIV, suggesting the importance of sexual health intervention and education programs for college students. Key words: HIV testing, sexual communication, sex, race/ethnicity, body image Am J Health Behav. 2014;38(6):816-822 DOI: http://dx.doi.org/10.5993/AJHB.38.6.3
HIV testing and communication in a racially/ethnically diverse sample of emerging adults who are in college. HIV testing confers a number of benefits for oneself, one’s partner, and for one’s child (among women who are pregnant or hope to become pregnant);6 however, the rate of testing among college students is low. Prevalence rates range from 10% to 46%.1,3,8-12 Some research shows no sex or racial/ethnic differences in HIV testing rates,3 although other studies suggest higher testing rates in women8 and in men.13 In terms of race/ethnicity, research generally indicates higher testing rates among African Americans,1,9,13 although in one study HIV testing rates were also high among Hispanics and “Others.”8 There is less research on communicating with a partner about HIV; instead, most of this work examines communication about sexual issues more generally, and reveals that students’ skills in communicating with a partner about safer sex could use improvement.2 For example, among US college students, although more than half (55.8%) report that they are “very comfortable” asking their partner to get an HIV test, only 25.2% to 27% report that their current partner actually had this test.3,12 Past research indicates that there are no sex or racial/ethnic differences in requesting that a partner obtain an HIV test.3 HIV testing and communication, as behaviors that serve to protect the body from harm, may be related to how individuals feel about their bodies. Maintaining positive feelings about one’s body may be challenging in Western cultures that tend to
Gillen & Markey objectify women’s bodies and increasingly objectify men’s bodies as well.14,15 Visual and dynamic media, particularly on the Internet, convey the importance of individuals’ physical appearance as central to their self-worth. According to Objectification Theory,14 our bodies can be understood only in the context of a social world that values beauty, thinness, and physical perfection, while often disparaging and devaluing individuals who do not aim to achieve physical ideals. Individuals come to view their bodies through the lens of their cultural context and as their more proximal interaction partners (eg, their parents, significant others) view their bodies. This often leads individuals to internalize negative messages about their bodies, experience distress, and even may lead to impaired judgment in some situations. For example, Fredrickson et al16 have found that individuals’ appearance-focus actually may be a drain on their cognitive resources. In one study they asked female college students to complete math problems while wearing either a sweater or a bathing suit (participants were randomly assigned to a condition and the study was guised as a market research study of clothing products). The women who wore bathing suits performed more poorly on the math problems when compared to the women who wore sweaters. These findings suggest the potential for physical concerns to distract individuals, perhaps women in particular, from logical thinking. Consistent with objectification theory and research supporting the distracting and obtrusive nature of feeling objectified, individuals who value their bodies and resist objectification, thereby maintaining the cognitive energy to address nonappearance related issues, may engage in safer sex behaviors to reduce their risk for acquiring STIs. The present study focused on potential connections among body image and HIV testing and communication with a partner about HIV. Body image is a multi-faceted construct, encompassing how individuals feel, perceive, think, and behave with regard to their bodies.17 Two aspects of body image were included in the current study: appearance orientation (cognitive and behavioral investment in appearance) and appearance evaluation (overall positive/negative evaluation of appearance).18 Although researchers have examined how orientation toward and evaluation of appearance is linked to sexual experience among college students,19,20 we know of no work on body image, HIV testing, and communication with a partner about HIV in this population. Research demonstrates that more positive views of the body are associated with more protective sexual attitudes. For example, adolescent girls who are more satisfied with their bodies are less likely to fear potential outcomes of negotiating condom use and perceive more control in their sexual relationships.21 Yamamiya et al22 found that women with more positive body image in sexual contexts reported less ambivalence in sexual decision-
making and less emotional disengagement during sex. Similar associations have been found among adolescent boys: those with higher body satisfaction report greater clarity in their sexual needs and values and in communicating sexual desires to a partner.23 Body image is not only related to sexual attitudes, but also to behavior within sexual contexts. Women who engage in more body surveillance (a construct similar to appearance orientation) report more substance use before sex.24 Further, men (but not women) who are more oriented toward their appearance report having had more lifetime sex partners.20 Evaluation of appearance is also linked to sexual behavior. Girls and women with more positive attitudes about their appearance or bodies report more condom use,20,21 and women with less body shame have fewer sex partners.24 Among men, however, those with more positive evaluations of their appearance report less condom use and more lifetime sexual partners.20 In support of objectification theory, it may be that individuals who report higher levels of appearance-related focus also report a greater likelihood of engaging in behaviors that compromise their sexual health. Evaluating one’s appearance positively, and resisting Western cultures’ objectification of the human body, may be associated with more confidence asserting sexual needs with a partner and in protecting oneself in sexual situations. In sum, the present study focused on the roles of sex, race/ethnicity, and body image in HIV testing and communication with a partner about HIV. Although some researchers have examined sex and racial/ethnic differences in HIV testing decisions,8,9 there is much less work on group differences in communication with a partner about HIV. There is a growing literature on body image and sexual behaviors and attitudes;19,20,22 however, there is little research specifically focusing on how body image may contribute to HIV testing and communication decisions. To that end, the goals of the present study are as follows: To examine HIV testing rates and rates of communicating with a partner about HIV, including whether these rates vary by sex and race/ethnicity. To examine associations between body image (appearance orientation and appearance evaluation) and HIV testing and communication with a partner about HIV.
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METHOD Participants and Procedures Undergraduate students (N = 277) at a nonresidential college in the northeastern United States participated in a research study on college students’ health in the year 2010. Recruitment focused on students ages 18 to 25 because this period of life (ie, emerging adulthood) tends to be marked by sexual exploration, experimentation, and risk behaviors.1,25 Recruitment methods
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Body Image and HIV Risk among College Students
Table 1 Demographic Characteristics and HIV Testing and Communication Rates M
SD
Age
19.27
1.35
BMI
23.94
5.04
% Sex Women
53
Men
47
Race/ethnicity European American/White
43
Asian American/Asian
33
African American/Black
16
Latino American/Hispanic
2
Other
6
Sexually active
57
Ever had HIV test
30a
Ever asked partner’s HIV status
20
Ever asked partner to get HIV test
14
Note. a = percent among sexually active students
included posting flyers around campus, visiting classes to announce the study (after emailing the faculty list serve and receiving instructor approval for coming to class), and emailing the student listserv. Participants provided informed consent and took a 32-page paper-and-pencil survey in a room on campus; they completed the survey in one sitting. The survey took approximately 30 – 45 minutes to complete, and participants received $20 for participating. Demographic characteristics for the sample are noted in Table 1. Measures Body image. Appearance orientation and appearance evaluation were measured by the Multidimensional Body-Self Relations Questionnaire.18 The appearance orientation subscale assesses cognitive and behavioral investment in appearance (eg, 12 items, “I am always trying to improve my physical appearance”). The appearance evaluation subscale measures overall feelings of physical attractiveness or unattractiveness (eg, 7 items, “I like my looks just the way they are”). Responses for both subscales range from 1 = definitely disagree to 5 = definitely agree, and total scores represent the average of items in each subscale. Reliability scores in the current study for appearance orientation (α = .83) and appearance evaluation (α = .86) were satisfactory.
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Body mass index (BMI). Students reported their height and weight and from these values BMI was estimated.26 BMI was used as a control variable in the analyses because it may be related to body image. In the current study, BMI was significantly correlated with appearance evaluation (r = -.21, p = .001), but not appearance orientation (r = -.02, p > .05). Sexual experience. Participants were asked if they had ever had penetrative sex, defined as “sex in which the penis penetrates the vagina or anus.” Response options were yes or no. Only participants who responded “yes” were included in analyses on HIV testing because testing is most relevant to those who are sexually active (N = 156). All participants were included in analyses on HIV communication with a partner because this communication may occur among students whether they are sexually active or not. For example, this information could be used by any student to inform decisions about whether or not to have penetrative sex with a potential partner. HIV testing. Participants responded to one question about HIV testing: “Have you ever had an HIV antibody test?” Response options were yes or no. HIV communication with a partner. Communication with a partner about HIV was defined as any communication that may elicit information about a partner’s HIV status. Participants responded to 2 questions: “Have you ever asked a partner what their HIV status is?” and “Have you ever asked a partner to have an HIV antibody test?” Response options were yes or no. RESULTS To address the first study goal of examining HIV testing rates and rates of communicating with a partner about HIV, simple percentages and chisquares to test for sex and racial/ethnic differences were calculated. The overall percentages of students who had ever had an HIV test and communicated with a partner about HIV are noted in Table 1. Obtaining an HIV test was associated with both asking a partner their HIV status, χ2(1, 156) = 13.23, p < .001, and asking a partner to have an HIV test, χ2(1, 156) = 33.33, p < .001. There were significant sex differences in HIV testing. Women were more likely than men to have obtained an HIV test χ2(1, 156) = 6.15, p < .05. However, there was no sex difference in HIV communication decisions (p values > .05). There were racial/ethnic differences in HIV testing and communication about HIV. In these analyses, African-American/ black students were compared to students in all other racial/ethnic groups given previous research showing higher HIV testing rates among African Americans/Blacks.1,9 African-American/black students were more likely to have ever obtained an HIV test, χ2(1, 156) = 18.91, p < .001, more likely to have ever asked a partner their HIV status, χ2(1, 275) = 9.29, p < .01, and more likely to have ever asked a partner to have an HIV test, χ2(1, 275) =
Gillen & Markey
Table 2 Logistic Regressions Predicting HIV Testing and Communication Variable
Wald χ2
Odds Ratios
95% Confidence Intervals
4.13*
2.25
1.03, 4.93
12.17***
Ever had HIV test Step 1 Sex African American/Black BMI
5.27
2.07, 13.41
.12
1.02
0.93, 1.12
Step 2 Sex
--
--
--
African American/Black
--
--
--
BMI
--
--
--
Appearance orientation
--
--
--
Appearance evaluation
--
--
--
1.56
1.51
0.79, 2.86
10.03**
3.46
1.61, 7.47
3.24
.94
0.87, 1.01
Ever asked partner’s HIV status Step 1 Sex African American/Black BMI Step 2 Sex
2.89
1.81
0.91, 3.59
African American/Black
5.31*
2.67
1.16, 6.14
BMI
1.38
.96
0.89, 1.03
Appearance orientation
.80
.79
0.47, 1.32
Appearance evaluation
9.70**
2.16
1.33, 3.50
Ever asked partner to have HIV test Step 1 Sex African American/Black BMI
.51
1.31
0.62, 2.77
17.51***
5.66
2.51, 12.75
.64
.97
0.90, 1.04
Step 2 Sex African American/Black BMI
.82
1.43
0.66, 3.12
12.04**
4.71
1.96, 11.31
.10
.99
0.92, 1.06
Appearance orientation
.59
.79
0.44, 1.44
Appearance evaluation
6.04*
1.97
1.15, 3.39
*p < .05, **p < .01, ***p < .001 Note. Sample sizes were N = 155 for the ever had HIV test model, and N = 271 for the ever asked partner’s HIV status and ever asked partner to have HIV test models. Variables were coded as: Sex (1 = men, 2 = women), and African American/Black (1 = African American/Black, 0 = all other racial/ethnic groups). Dashes indicate that step was not significant.
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Body Image and HIV Risk among College Students 22.36, p < .001 as compared to students in other racial/ethnic groups. To address the second study goal of whether or not body image is related to HIV testing behavior and communication with a partner about HIV, 3 logistic regressions were performed. We performed each regression in 2 steps, with Step 1 including demographic variables, and Step 2 including body image variables to determine the impact of body image on the outcomes above and beyond demographics. Specifically, Step 1 included sex (1 = men, 2 = women), African-American/black race/ ethnicity (1 = African American/Black, 0 = all other racial/ethnic groups), and BMI centered at its mean. Step 2 included appearance orientation and appearance evaluation centered at their means. The outcomes were the 3 questions about HIV. In the model on ever obtaining an HIV test, the second step did not add a significant amount of variance (p > .05). The first step, however, did add a significant amount of variance and the overall model was statistically significant, χ2(3, 155) = 21.52, p < .001 (Table 2). In this step, women and African Americans/Blacks had a greater likelihood of ever obtaining an HIV test than men and students in other racial/ethnic groups, respectively. The full models for ever asking a partner’s HIV status, χ2(5, 271) = 25.67, p < .001 and ever asking a partner to have an HIV test χ2(5, 271) = 25.90, p < .001 were also statistically significant, and the second steps in these models added a significant amount of variance (p values < .05; Table 2). In the second steps of both models, African-American/black race/ethnicity and appearance evaluation were significant predictors. African Americans/Blacks had a greater likelihood of asking a partner’s HIV status and asking a partner to get an HIV test as compared to those in other racial/ethnic groups. As appearance evaluation increased, the likelihood of asking a partner’s HIV status and the likelihood of asking a partner to have an HIV test increased as well. DISCUSSION This study examined rates of HIV testing and communication with a partner about HIV in a sample of racially/ethnically diverse emerging adults at a nonresidential college campus. Results indicate that the rate of HIV testing among sexually active students is low (30%) and comparable to the rates reported in prior studies.3,11 HIV testing confers the benefit of gaining knowledge about one’s own health status, which can facilitate more informed sexual decision-making, and if needed, appropriate medical care.6 Considering that college students have high rates of unprotected sexual behavior that may place them at risk for acquiring HIV,2 it is critical that HIV testing rates increase. College campuses should offer STI testing, ideally on campus (eg, regular testing services and designated days for testing)9 or partner with local organizations that can provide this service. Testing services should be advertised widely around campus
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to increase awareness of their availability, and potentially, to reduce any shame or stigma surrounding this issue. Medical staff at college health centers should also encourage students to get tested whenever they visit these centers.9 However, availability and convenience may not be enough; some research suggests that motivation among students is a significant barrier to getting tested.3,9 Specifically, approximately one-half of sexually active college students report no motivation to get tested for HIV, chlamydia, and/or gonorrhea in the next 3 months, with the most important reason cited being lack of perceived risk.9 Intervention programs on college campuses should emphasize that merely being sexually active is a risk factor for acquiring an STI (although having multiple partners and using protection inconsistently may raise that risk). Given that most college students are sexually active,1,20 getting tested for HIV is critical for students’ health. Results also show that most students do not communicate with a partner about HIV; no more than one out of 5 students ever has asked their partner’s HIV status or asked their partner to get tested for HIV. Previous studies on college students have suggested similar results.3,9 For example, Shapiro et al3 found that although more than half of students report that they are “very comfortable” asking a partner about his/her sexual history and asking a partner to get tested for HIV, these attitudes do not appear to translate into behavior. Students may feel comfortable in abstract terms, but feel unsure of what to say when they actually find themselves in these situations. Although communication about HIV may be informative, it is important to recognize that some individuals may lie about, or fail to disclose, their HIV status.12,27 For example, 5% of sexually active college students admit telling a previous sexual partner that they did not have HIV even though they had never actually been tested.27 Nonetheless, given the CDC’s recommendation that medical staff inform patients that they and their future partners get tested for HIV before having sex,7 communication strategies surrounding this sensitive topic seem particularly important. Perhaps students need skills training on how to engage in conversations about HIV and other STIs with a partner.2 Colleges might offer this training as part of extracurricular activities, leadership certificate programs, or Greek life programs, with a trained peer and/or mental health provider as facilitators. Less communication with a partner about sexual issues is associated with riskier sexual behavior, such as less condom/contraceptive use and recent sex with a non-regular partner.28,29 Improving these communication skills, then, may not only help people clarify their sexual needs and values to their partners (eg, “I will not have sex with someone unless I know their HIV status”), but also may be linked to safer sex behaviors within relationships. Although rates of HIV testing and communica-
Gillen & Markey tion were low overall, women were more likely to have ever had an HIV test than men. Women are socialized to focus on their health (in particular, their reproductive health) and to obtain needed medical care,30 and may visit an obstetrician/gynecologist for birth control whereas there is no comparable doctor for men. With regard to HIV in particular, women are biologically more susceptible to acquiring HIV31 and report more motivation to acquire an HIV test than men.9 These factors may explain women’s higher testing rates. AfricanAmerican/black students were significantly more likely to have ever had an HIV test, to ask a partner his/her HIV status, and to have asked a partner to get an HIV test when compared to students in other racial/ethnic groups. Perception of risk may explain these findings, as this is an important motivating factor in HIV testing decisions among college students3,9 and African Americans/Blacks are, in fact, disproportionately affected by HIV.4 However, other research suggests that perceived risk is not a significant motivating factor among African Americans to get tested for HIV perhaps due to denial and fear.32,33African-American/black students may perceive greater racism than other students, a factor that has been linked with health protective measures among African Americans, including a greater likelihood of getting tested for HIV.33,34 It is possible that these perceptions also may confer health protective benefits with regard to communicating with a partner about HIV. In addition to sex and race/ethnicity, body image was considered as a factor in students’ decisions to obtain an HIV test and to communicate with a partner about HIV. Students who had more positive views of their appearance had a greater likelihood of ever asking a partner’s HIV status and ever asking a partner to get tested for HIV, even after controlling for demographic factors. These results are similar to prior research demonstrating that positive body image is associated with safer-sex attitudes and behaviors among girls and women.21,22 Further, these findings support objectification theory.14 Individuals who resist objectification and have more positive views of their appearance may feel more confident in sexual situations because of their comfort with and confidence in their bodies. This confidence in appearance may not only include greater comfort engaging in sexual activities (eg, having sex with the lights on or undressing in front of a partner),35 but also engaging in sex-related communication with a partner. It is interesting, however, that body image was not associated with ever obtaining an HIV test. Perhaps positive body image gives individuals confidence in dyadic contexts where their appearance is more pertinent, such as sexual situations, yet, may be less relevant to other body-related decisions where appearance seems less significant. Considering the important role of body image in students’ communication about HIV risk, college campuses may wish to consider integrating information on posi-
tive body image into sexual health programs. However, encouraging positive body image may not be enough; addressing students’ perceived invulnerability and other barriers to testing (eg, fear, convenience) is critical as well.
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Limitations and Conclusions This study has several limitations including a relatively modest sample size, cross-sectional design, and examination of relations between current body image and lifetime HIV testing and communication. The latter 2 limitations prevent causal inferences from being made about relations among variables. Nonetheless, this study added to the literature on communication with a partner about HIV, as there is little research on this topic among college students. To our knowledge, this study was also the first work to focus on how body image might contribute to both HIV testing and communication decisions. Findings suggest low prevalence rates of HIV testing and communication with a partner about HIV, although there were group differences in these behaviors by sex and race/ethnicity. Notably, African-American/black students were more likely to engage in these safer-sex behaviors than students from other racial/ethnic groups. All emerging adult students in college could benefit from interventions that seek to increase their willingness to obtain an HIV test and their skill in discussing these sensitive issues with partners. Results also indicated that body image played an important role in communicating with a partner about HIV in ways consistent with objectification theory.14 Future studies should continue to examine links between body image and safer-sex behaviors. For example, researchers could study the role of body image in communicating with a partner about other STIs (eg, chlamydia) and pregnancy prevention. Because body image reflects how individuals evaluate and feel about their bodies,17 it may be an important factor to consider in sexuality research and intervention programming. Human Subjects Statement This study was approved by the university’s Institutional Review Board. Conflict of Interest Statement The authors declare no conflict of interest. Acknowledgements A previous version of this manuscript was presented at the Society for Research on Adolescence 2012 Biennial Meeting, Vancouver, Canada. This research was supported by awards to Meghan M. Gillen from Penn State University, including the Rubin Psychological and Social Sciences Award. We gratefully acknowledge Gianna Bowler, Jeremy Capelotti, Katherine Gillmor, Rochelle Grant, Christina Rutledge, and Patrick Woodruff for their help with study design, data collection, scoring,
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Body Image and HIV Risk among College Students entering, cleaning, and analyses, as well as manuscript preparation. References
1. Buhi ER, Marhefka SL, Hoban MT. The state of the union: sexual health disparities in a national sample of U.S. college students. J Am Coll Health. 2010;58(4):337-346. 2. Lewis JE, Miguez-Burbano M, Malow RM. HIV risk behavior among college students in the United States. Coll Stud J. 2009;43(2):475-491. 3. Shapiro J, Radecki S, Charchian AS, Josephson V. Sexual behavior and AIDS-related knowledge among community college students in Orange County, California. J Community Health. 1999;24(1):29-43. 4. Centers for Disease Control and Prevention. HIV/AIDS: Basic statistics. Available at: http://www.cdc.gov/hiv/ basics/statistics.html. Accessed May 20, 2014. 5. Centers for Disease Control and Prevention. HIV/AIDS: Living with HIV. Available at: http://www.cdc.gov/hiv/ living/index.html. Accessed May 20, 2014. 6. Centers for Disease Control and Prevention. HIV/AIDS: Testing. Available at: http://www.cdc.gov/hiv/basics/ testing.html. Accessed May 20, 2014. 7. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR14):1-17. 8. Caldeira KM, Singer BJ, O’Grady KE, et al. HIV testing in recent college students: prevalence and correlates. AIDS Educ Prev. 2012;24(4):363-376. 9. Moore EW. Human immunodeficiency virus and chlamydia/gonorrhea testing among heterosexual college students. J Am Coll Health. 2013;61(4):196-202. 10. Scholly K, Katz AR, Gascoigne J, Holck PS. Using social norms theory to explain perceptions and sexual health behaviors of undergraduate college students: an exploratory study. J Am Coll Health. 2005;53(4):159-166. 11. Trieu SL, Modeste NN, Marshak HH, et al. Partner communication and HIV testing among US Chinese college students. Am J Health Behav. 2010;34(3):362-373. 12. Simkins L. Risk of HIV transmission in sexual behaviors of college students. Psychol Rep. 1995;76(3):787-799. 13. Valentine PA, Wright DL, Henley GL. Patterns of safer sex practices among allied health students at historically black colleges and universities. J Allied Health. 2003;32(3):173-178. 14. Fredrickson BL, Roberts TA. Objectification theory: toward understanding women’s lived experiences and mental health risks. Psychol Women Q. 1997;21(2):173206. 15. McCreary DR. Body image and muscularity. In Cash TF, Smolak L, eds. Body Image: A Handbook of Science, Practice and Prevention. 2nd ed. New York, NY: Guilford Press; 2011:198-205. 16. Fredrickson BL, Roberts TA, Noll SM, et al. That swimsuit becomes you: sex differences in self-objectification, restrained eating, and math performance. J Pers Soc Psychol. 1998;75:269-284. 17. Gillen MM, Markey CN. Body image and mental health. In Friedman HS, ed. Encyclopedia of Mental Health. 2nd ed. Oxford, UK: Elsevier; in press. 18. Cash TF. The Multi-Dimensional Body-Self Relations Questionnaire. 2000. Available at: http://www.body-
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images.com/assessments/mbsrq.html. Accessed May 20, 2014. 19. Vasilenko SA, Ram N, Lefkowitz ES. Body image and first sexual intercourse in late adolescence. J Adolesc. 2011;34(2):327-335. 20. Gillen MM, Lefkowitz ES, Shearer CL. Does body image play a role in risky sexual behavior and attitudes? J Youth Adolesc. 2006;35(2):243-255. 21. Wingood GM, DiClemente RJ, Harrington K, Davies SL. Body image and African American females’ sexual health. J Womens Health Gend Based Med. 2002;11(5):433-439. 22. Yamamiya Y, Cash TF, Thompson JK. Sexual experiences among college women: the differential effects of general versus contextual body images on sexuality. Sex Roles. 2006;55(5-6):421-427. 23. Schooler D, Impett EA, Hirschman C, Bonem L. A mixed-method exploration of body image and sexual health among adolescent boys. Am J Mens Health. 2008;2(4):322-339. 24. Littleton H, Breitkopf CR, Berenson A. Body image and risky sexual behaviors: an investigation in a tri-ethnic sample. Body Image. 2005;2(2):193-198. 25. Lefkowitz ES, Gillen MM. “Sex is just a normal part of life”: Sexuality in emerging adulthood. In: Arnett JJ, Tanner JL, editors. Coming of Age in the Twenty-First Century: The Lives and Contexts of Emerging Adults. Washington, DC: American Psychological Association; 2005: 235-255. 26. Centers for Disease Control and Prevention. About BMI for adults. Available at: http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html. Accessed May 20, 2014. 27. Marelich WD, Clark T. Human immunodeficiency virus (HIV) testing and false disclosures in heterosexual college students. J Am Coll Health. 2004;53(3):109-115. 28. Crosby RA, DiClemente RJ, Wingood GM, et al. Condom use and correlates of African American adolescent females’ infrequent communication with sex partners about preventing sexually transmitted diseases and pregnancy. Health Educ Behav. 2002;29(2):219-231. 29. Widman L, Welsh DP, McNulty JK, Little KC. Sexual communication and contraceptive use in adolescent dating couples. J Adolesc Health. 2006;39(6):893-899. 30. Chrisler JC. Gendered bodies and physical health. In Unger RK, ed. Handbook of the Psychology Women and Gender. New York, NY: Wiley; 2001:289-302. 31. Higgins JA, Hoffman S, Dworkin SL. Rethinking gender, heterosexual men, and women’s vulnerability to HIV/ AIDS. Am J Public Health. 2010(3);100:435-445. 32. Ford CL, Daniel M, Miller WC. High rates of HIV testing despite low perceived HIV risk among African-American sexually transmitted disease patients. J Natl Med Assoc. 2006;98(6):841-844. 33. Ford CL, Daniel M, Earp JL, et al. Perceived everyday racism, residential segregation, and HIV testing among patients at a sexually transmitted disease clinic. Am J Public Health. 2009;99(S1):S137-S143. 34. Vines AI, Baird DD, Stevens J, et al. Associations of abdominal fat with perceived racism and passive emotional responses to racism in African American women. Am J Public Health. 2007:97(3):526-530. 35. Ackard DM, Kearney-Cooke A, Peterson CB. Effect of body image and self-image on women’s sexual behaviors. Int J Eat Disord. 2000;28(4):422-429.
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ollege students engage in high rates of risky sexual behavior,1-3 thereby increasing their risk for acquiring sexually transmitted infections (STIs). HIV (human immunodeficiency virus) is a particularly serious STI as it can lead to health complications and death.4,5 Approximately 1.1 million people in the United States have HIV, with African Americans and young people ages 13 – 24 being disproportionately affected.4 However, some people who are infected with HIV may be unaware of their HIV status. In fact, as many as 16% of people who have the virus do not know they have it.4 Obtaining an HIV test, which is recommended as part of routine healthcare for adolescents and adults, is the only effective means of knowing one’s status and may help reduce the spread of infection by shaping one’s own as well as one’s partner’s sexual choices.6,7 Communicating with a partner about one’s HIV status also may be important in determining people’s future sexual behavior. In fact, the Centers for Disease Control and Prevention (CDC)7 recommends that medical practitioners communicate to their patients that both them and their potential future partners should get tested before engaging in sexual behavior. The goal of the current study was to examine how sex, race/ethnicity, and body image may be related to Meghan M. Gillen, Assistant Professor, Pennsylvania State University, Division of Social Sciences, Abington, PA. Charlotte N. Markey, Associate Professor, Rutgers University, Department of Psychology, Camden, NJ. Correspondence Dr Gillen; [email protected]
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more likely to have ever asked a partner’s HIV status and to have asked a partner to get tested for HIV. Conclusions: Findings indicate low rates of HIV testing and communication with a partner about HIV, suggesting the importance of sexual health intervention and education programs for college students. Key words: HIV testing, sexual communication, sex, race/ethnicity, body image Am J Health Behav. 2014;38(6):816-822 DOI: http://dx.doi.org/10.5993/AJHB.38.6.3
HIV testing and communication in a racially/ethnically diverse sample of emerging adults who are in college. HIV testing confers a number of benefits for oneself, one’s partner, and for one’s child (among women who are pregnant or hope to become pregnant);6 however, the rate of testing among college students is low. Prevalence rates range from 10% to 46%.1,3,8-12 Some research shows no sex or racial/ethnic differences in HIV testing rates,3 although other studies suggest higher testing rates in women8 and in men.13 In terms of race/ethnicity, research generally indicates higher testing rates among African Americans,1,9,13 although in one study HIV testing rates were also high among Hispanics and “Others.”8 There is less research on communicating with a partner about HIV; instead, most of this work examines communication about sexual issues more generally, and reveals that students’ skills in communicating with a partner about safer sex could use improvement.2 For example, among US college students, although more than half (55.8%) report that they are “very comfortable” asking their partner to get an HIV test, only 25.2% to 27% report that their current partner actually had this test.3,12 Past research indicates that there are no sex or racial/ethnic differences in requesting that a partner obtain an HIV test.3 HIV testing and communication, as behaviors that serve to protect the body from harm, may be related to how individuals feel about their bodies. Maintaining positive feelings about one’s body may be challenging in Western cultures that tend to
Gillen & Markey objectify women’s bodies and increasingly objectify men’s bodies as well.14,15 Visual and dynamic media, particularly on the Internet, convey the importance of individuals’ physical appearance as central to their self-worth. According to Objectification Theory,14 our bodies can be understood only in the context of a social world that values beauty, thinness, and physical perfection, while often disparaging and devaluing individuals who do not aim to achieve physical ideals. Individuals come to view their bodies through the lens of their cultural context and as their more proximal interaction partners (eg, their parents, significant others) view their bodies. This often leads individuals to internalize negative messages about their bodies, experience distress, and even may lead to impaired judgment in some situations. For example, Fredrickson et al16 have found that individuals’ appearance-focus actually may be a drain on their cognitive resources. In one study they asked female college students to complete math problems while wearing either a sweater or a bathing suit (participants were randomly assigned to a condition and the study was guised as a market research study of clothing products). The women who wore bathing suits performed more poorly on the math problems when compared to the women who wore sweaters. These findings suggest the potential for physical concerns to distract individuals, perhaps women in particular, from logical thinking. Consistent with objectification theory and research supporting the distracting and obtrusive nature of feeling objectified, individuals who value their bodies and resist objectification, thereby maintaining the cognitive energy to address nonappearance related issues, may engage in safer sex behaviors to reduce their risk for acquiring STIs. The present study focused on potential connections among body image and HIV testing and communication with a partner about HIV. Body image is a multi-faceted construct, encompassing how individuals feel, perceive, think, and behave with regard to their bodies.17 Two aspects of body image were included in the current study: appearance orientation (cognitive and behavioral investment in appearance) and appearance evaluation (overall positive/negative evaluation of appearance).18 Although researchers have examined how orientation toward and evaluation of appearance is linked to sexual experience among college students,19,20 we know of no work on body image, HIV testing, and communication with a partner about HIV in this population. Research demonstrates that more positive views of the body are associated with more protective sexual attitudes. For example, adolescent girls who are more satisfied with their bodies are less likely to fear potential outcomes of negotiating condom use and perceive more control in their sexual relationships.21 Yamamiya et al22 found that women with more positive body image in sexual contexts reported less ambivalence in sexual decision-
making and less emotional disengagement during sex. Similar associations have been found among adolescent boys: those with higher body satisfaction report greater clarity in their sexual needs and values and in communicating sexual desires to a partner.23 Body image is not only related to sexual attitudes, but also to behavior within sexual contexts. Women who engage in more body surveillance (a construct similar to appearance orientation) report more substance use before sex.24 Further, men (but not women) who are more oriented toward their appearance report having had more lifetime sex partners.20 Evaluation of appearance is also linked to sexual behavior. Girls and women with more positive attitudes about their appearance or bodies report more condom use,20,21 and women with less body shame have fewer sex partners.24 Among men, however, those with more positive evaluations of their appearance report less condom use and more lifetime sexual partners.20 In support of objectification theory, it may be that individuals who report higher levels of appearance-related focus also report a greater likelihood of engaging in behaviors that compromise their sexual health. Evaluating one’s appearance positively, and resisting Western cultures’ objectification of the human body, may be associated with more confidence asserting sexual needs with a partner and in protecting oneself in sexual situations. In sum, the present study focused on the roles of sex, race/ethnicity, and body image in HIV testing and communication with a partner about HIV. Although some researchers have examined sex and racial/ethnic differences in HIV testing decisions,8,9 there is much less work on group differences in communication with a partner about HIV. There is a growing literature on body image and sexual behaviors and attitudes;19,20,22 however, there is little research specifically focusing on how body image may contribute to HIV testing and communication decisions. To that end, the goals of the present study are as follows: To examine HIV testing rates and rates of communicating with a partner about HIV, including whether these rates vary by sex and race/ethnicity. To examine associations between body image (appearance orientation and appearance evaluation) and HIV testing and communication with a partner about HIV.
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METHOD Participants and Procedures Undergraduate students (N = 277) at a nonresidential college in the northeastern United States participated in a research study on college students’ health in the year 2010. Recruitment focused on students ages 18 to 25 because this period of life (ie, emerging adulthood) tends to be marked by sexual exploration, experimentation, and risk behaviors.1,25 Recruitment methods
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Body Image and HIV Risk among College Students
Table 1 Demographic Characteristics and HIV Testing and Communication Rates M
SD
Age
19.27
1.35
BMI
23.94
5.04
% Sex Women
53
Men
47
Race/ethnicity European American/White
43
Asian American/Asian
33
African American/Black
16
Latino American/Hispanic
2
Other
6
Sexually active
57
Ever had HIV test
30a
Ever asked partner’s HIV status
20
Ever asked partner to get HIV test
14
Note. a = percent among sexually active students
included posting flyers around campus, visiting classes to announce the study (after emailing the faculty list serve and receiving instructor approval for coming to class), and emailing the student listserv. Participants provided informed consent and took a 32-page paper-and-pencil survey in a room on campus; they completed the survey in one sitting. The survey took approximately 30 – 45 minutes to complete, and participants received $20 for participating. Demographic characteristics for the sample are noted in Table 1. Measures Body image. Appearance orientation and appearance evaluation were measured by the Multidimensional Body-Self Relations Questionnaire.18 The appearance orientation subscale assesses cognitive and behavioral investment in appearance (eg, 12 items, “I am always trying to improve my physical appearance”). The appearance evaluation subscale measures overall feelings of physical attractiveness or unattractiveness (eg, 7 items, “I like my looks just the way they are”). Responses for both subscales range from 1 = definitely disagree to 5 = definitely agree, and total scores represent the average of items in each subscale. Reliability scores in the current study for appearance orientation (α = .83) and appearance evaluation (α = .86) were satisfactory.
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Body mass index (BMI). Students reported their height and weight and from these values BMI was estimated.26 BMI was used as a control variable in the analyses because it may be related to body image. In the current study, BMI was significantly correlated with appearance evaluation (r = -.21, p = .001), but not appearance orientation (r = -.02, p > .05). Sexual experience. Participants were asked if they had ever had penetrative sex, defined as “sex in which the penis penetrates the vagina or anus.” Response options were yes or no. Only participants who responded “yes” were included in analyses on HIV testing because testing is most relevant to those who are sexually active (N = 156). All participants were included in analyses on HIV communication with a partner because this communication may occur among students whether they are sexually active or not. For example, this information could be used by any student to inform decisions about whether or not to have penetrative sex with a potential partner. HIV testing. Participants responded to one question about HIV testing: “Have you ever had an HIV antibody test?” Response options were yes or no. HIV communication with a partner. Communication with a partner about HIV was defined as any communication that may elicit information about a partner’s HIV status. Participants responded to 2 questions: “Have you ever asked a partner what their HIV status is?” and “Have you ever asked a partner to have an HIV antibody test?” Response options were yes or no. RESULTS To address the first study goal of examining HIV testing rates and rates of communicating with a partner about HIV, simple percentages and chisquares to test for sex and racial/ethnic differences were calculated. The overall percentages of students who had ever had an HIV test and communicated with a partner about HIV are noted in Table 1. Obtaining an HIV test was associated with both asking a partner their HIV status, χ2(1, 156) = 13.23, p < .001, and asking a partner to have an HIV test, χ2(1, 156) = 33.33, p < .001. There were significant sex differences in HIV testing. Women were more likely than men to have obtained an HIV test χ2(1, 156) = 6.15, p < .05. However, there was no sex difference in HIV communication decisions (p values > .05). There were racial/ethnic differences in HIV testing and communication about HIV. In these analyses, African-American/ black students were compared to students in all other racial/ethnic groups given previous research showing higher HIV testing rates among African Americans/Blacks.1,9 African-American/black students were more likely to have ever obtained an HIV test, χ2(1, 156) = 18.91, p < .001, more likely to have ever asked a partner their HIV status, χ2(1, 275) = 9.29, p < .01, and more likely to have ever asked a partner to have an HIV test, χ2(1, 275) =
Gillen & Markey
Table 2 Logistic Regressions Predicting HIV Testing and Communication Variable
Wald χ2
Odds Ratios
95% Confidence Intervals
4.13*
2.25
1.03, 4.93
12.17***
Ever had HIV test Step 1 Sex African American/Black BMI
5.27
2.07, 13.41
.12
1.02
0.93, 1.12
Step 2 Sex
--
--
--
African American/Black
--
--
--
BMI
--
--
--
Appearance orientation
--
--
--
Appearance evaluation
--
--
--
1.56
1.51
0.79, 2.86
10.03**
3.46
1.61, 7.47
3.24
.94
0.87, 1.01
Ever asked partner’s HIV status Step 1 Sex African American/Black BMI Step 2 Sex
2.89
1.81
0.91, 3.59
African American/Black
5.31*
2.67
1.16, 6.14
BMI
1.38
.96
0.89, 1.03
Appearance orientation
.80
.79
0.47, 1.32
Appearance evaluation
9.70**
2.16
1.33, 3.50
Ever asked partner to have HIV test Step 1 Sex African American/Black BMI
.51
1.31
0.62, 2.77
17.51***
5.66
2.51, 12.75
.64
.97
0.90, 1.04
Step 2 Sex African American/Black BMI
.82
1.43
0.66, 3.12
12.04**
4.71
1.96, 11.31
.10
.99
0.92, 1.06
Appearance orientation
.59
.79
0.44, 1.44
Appearance evaluation
6.04*
1.97
1.15, 3.39
*p < .05, **p < .01, ***p < .001 Note. Sample sizes were N = 155 for the ever had HIV test model, and N = 271 for the ever asked partner’s HIV status and ever asked partner to have HIV test models. Variables were coded as: Sex (1 = men, 2 = women), and African American/Black (1 = African American/Black, 0 = all other racial/ethnic groups). Dashes indicate that step was not significant.
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Body Image and HIV Risk among College Students 22.36, p < .001 as compared to students in other racial/ethnic groups. To address the second study goal of whether or not body image is related to HIV testing behavior and communication with a partner about HIV, 3 logistic regressions were performed. We performed each regression in 2 steps, with Step 1 including demographic variables, and Step 2 including body image variables to determine the impact of body image on the outcomes above and beyond demographics. Specifically, Step 1 included sex (1 = men, 2 = women), African-American/black race/ ethnicity (1 = African American/Black, 0 = all other racial/ethnic groups), and BMI centered at its mean. Step 2 included appearance orientation and appearance evaluation centered at their means. The outcomes were the 3 questions about HIV. In the model on ever obtaining an HIV test, the second step did not add a significant amount of variance (p > .05). The first step, however, did add a significant amount of variance and the overall model was statistically significant, χ2(3, 155) = 21.52, p < .001 (Table 2). In this step, women and African Americans/Blacks had a greater likelihood of ever obtaining an HIV test than men and students in other racial/ethnic groups, respectively. The full models for ever asking a partner’s HIV status, χ2(5, 271) = 25.67, p < .001 and ever asking a partner to have an HIV test χ2(5, 271) = 25.90, p < .001 were also statistically significant, and the second steps in these models added a significant amount of variance (p values < .05; Table 2). In the second steps of both models, African-American/black race/ethnicity and appearance evaluation were significant predictors. African Americans/Blacks had a greater likelihood of asking a partner’s HIV status and asking a partner to get an HIV test as compared to those in other racial/ethnic groups. As appearance evaluation increased, the likelihood of asking a partner’s HIV status and the likelihood of asking a partner to have an HIV test increased as well. DISCUSSION This study examined rates of HIV testing and communication with a partner about HIV in a sample of racially/ethnically diverse emerging adults at a nonresidential college campus. Results indicate that the rate of HIV testing among sexually active students is low (30%) and comparable to the rates reported in prior studies.3,11 HIV testing confers the benefit of gaining knowledge about one’s own health status, which can facilitate more informed sexual decision-making, and if needed, appropriate medical care.6 Considering that college students have high rates of unprotected sexual behavior that may place them at risk for acquiring HIV,2 it is critical that HIV testing rates increase. College campuses should offer STI testing, ideally on campus (eg, regular testing services and designated days for testing)9 or partner with local organizations that can provide this service. Testing services should be advertised widely around campus
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to increase awareness of their availability, and potentially, to reduce any shame or stigma surrounding this issue. Medical staff at college health centers should also encourage students to get tested whenever they visit these centers.9 However, availability and convenience may not be enough; some research suggests that motivation among students is a significant barrier to getting tested.3,9 Specifically, approximately one-half of sexually active college students report no motivation to get tested for HIV, chlamydia, and/or gonorrhea in the next 3 months, with the most important reason cited being lack of perceived risk.9 Intervention programs on college campuses should emphasize that merely being sexually active is a risk factor for acquiring an STI (although having multiple partners and using protection inconsistently may raise that risk). Given that most college students are sexually active,1,20 getting tested for HIV is critical for students’ health. Results also show that most students do not communicate with a partner about HIV; no more than one out of 5 students ever has asked their partner’s HIV status or asked their partner to get tested for HIV. Previous studies on college students have suggested similar results.3,9 For example, Shapiro et al3 found that although more than half of students report that they are “very comfortable” asking a partner about his/her sexual history and asking a partner to get tested for HIV, these attitudes do not appear to translate into behavior. Students may feel comfortable in abstract terms, but feel unsure of what to say when they actually find themselves in these situations. Although communication about HIV may be informative, it is important to recognize that some individuals may lie about, or fail to disclose, their HIV status.12,27 For example, 5% of sexually active college students admit telling a previous sexual partner that they did not have HIV even though they had never actually been tested.27 Nonetheless, given the CDC’s recommendation that medical staff inform patients that they and their future partners get tested for HIV before having sex,7 communication strategies surrounding this sensitive topic seem particularly important. Perhaps students need skills training on how to engage in conversations about HIV and other STIs with a partner.2 Colleges might offer this training as part of extracurricular activities, leadership certificate programs, or Greek life programs, with a trained peer and/or mental health provider as facilitators. Less communication with a partner about sexual issues is associated with riskier sexual behavior, such as less condom/contraceptive use and recent sex with a non-regular partner.28,29 Improving these communication skills, then, may not only help people clarify their sexual needs and values to their partners (eg, “I will not have sex with someone unless I know their HIV status”), but also may be linked to safer sex behaviors within relationships. Although rates of HIV testing and communica-
Gillen & Markey tion were low overall, women were more likely to have ever had an HIV test than men. Women are socialized to focus on their health (in particular, their reproductive health) and to obtain needed medical care,30 and may visit an obstetrician/gynecologist for birth control whereas there is no comparable doctor for men. With regard to HIV in particular, women are biologically more susceptible to acquiring HIV31 and report more motivation to acquire an HIV test than men.9 These factors may explain women’s higher testing rates. AfricanAmerican/black students were significantly more likely to have ever had an HIV test, to ask a partner his/her HIV status, and to have asked a partner to get an HIV test when compared to students in other racial/ethnic groups. Perception of risk may explain these findings, as this is an important motivating factor in HIV testing decisions among college students3,9 and African Americans/Blacks are, in fact, disproportionately affected by HIV.4 However, other research suggests that perceived risk is not a significant motivating factor among African Americans to get tested for HIV perhaps due to denial and fear.32,33African-American/black students may perceive greater racism than other students, a factor that has been linked with health protective measures among African Americans, including a greater likelihood of getting tested for HIV.33,34 It is possible that these perceptions also may confer health protective benefits with regard to communicating with a partner about HIV. In addition to sex and race/ethnicity, body image was considered as a factor in students’ decisions to obtain an HIV test and to communicate with a partner about HIV. Students who had more positive views of their appearance had a greater likelihood of ever asking a partner’s HIV status and ever asking a partner to get tested for HIV, even after controlling for demographic factors. These results are similar to prior research demonstrating that positive body image is associated with safer-sex attitudes and behaviors among girls and women.21,22 Further, these findings support objectification theory.14 Individuals who resist objectification and have more positive views of their appearance may feel more confident in sexual situations because of their comfort with and confidence in their bodies. This confidence in appearance may not only include greater comfort engaging in sexual activities (eg, having sex with the lights on or undressing in front of a partner),35 but also engaging in sex-related communication with a partner. It is interesting, however, that body image was not associated with ever obtaining an HIV test. Perhaps positive body image gives individuals confidence in dyadic contexts where their appearance is more pertinent, such as sexual situations, yet, may be less relevant to other body-related decisions where appearance seems less significant. Considering the important role of body image in students’ communication about HIV risk, college campuses may wish to consider integrating information on posi-
tive body image into sexual health programs. However, encouraging positive body image may not be enough; addressing students’ perceived invulnerability and other barriers to testing (eg, fear, convenience) is critical as well.
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Limitations and Conclusions This study has several limitations including a relatively modest sample size, cross-sectional design, and examination of relations between current body image and lifetime HIV testing and communication. The latter 2 limitations prevent causal inferences from being made about relations among variables. Nonetheless, this study added to the literature on communication with a partner about HIV, as there is little research on this topic among college students. To our knowledge, this study was also the first work to focus on how body image might contribute to both HIV testing and communication decisions. Findings suggest low prevalence rates of HIV testing and communication with a partner about HIV, although there were group differences in these behaviors by sex and race/ethnicity. Notably, African-American/black students were more likely to engage in these safer-sex behaviors than students from other racial/ethnic groups. All emerging adult students in college could benefit from interventions that seek to increase their willingness to obtain an HIV test and their skill in discussing these sensitive issues with partners. Results also indicated that body image played an important role in communicating with a partner about HIV in ways consistent with objectification theory.14 Future studies should continue to examine links between body image and safer-sex behaviors. For example, researchers could study the role of body image in communicating with a partner about other STIs (eg, chlamydia) and pregnancy prevention. Because body image reflects how individuals evaluate and feel about their bodies,17 it may be an important factor to consider in sexuality research and intervention programming. Human Subjects Statement This study was approved by the university’s Institutional Review Board. Conflict of Interest Statement The authors declare no conflict of interest. Acknowledgements A previous version of this manuscript was presented at the Society for Research on Adolescence 2012 Biennial Meeting, Vancouver, Canada. This research was supported by awards to Meghan M. Gillen from Penn State University, including the Rubin Psychological and Social Sciences Award. We gratefully acknowledge Gianna Bowler, Jeremy Capelotti, Katherine Gillmor, Rochelle Grant, Christina Rutledge, and Patrick Woodruff for their help with study design, data collection, scoring,
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Body Image and HIV Risk among College Students entering, cleaning, and analyses, as well as manuscript preparation. References
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