HEALTH PSYCHOLOGY, 1992,11(4), 218-222 Copyright © 1992, Lawrence Erlbaum Associates, Inc.
Stress, Coping, and High-Risk Sexual Behavior Susan Folkman Center for AIDS Prevention Studies and Division of General Internal Medicine University of California, San Francisco
Margaret A. Chesney
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Center for AIDS Prevention Studies and Department of Epidemiology and Biostatistics University of California, San Francisco
Lance Pollack and Connie Phillips Center for AIDS Prevention Studies We examined the relation between stress, coping, and a high-risk sexual behavior (unprotected anal intercourse) in 398 nonmonogamous gay and bisexual men from the AIDS Behavioral Research Project in San Francisco. Unprotected anal intercourse during the previous month, the amount of stress experienced during the previous month in each of 10 domains, six types of coping (self-controlling coping, escape-avoidance, distancing, planful problem-solving, seeking social support, and positive reappraisal), and spiritual beliefs and spiritual activities were assessed through self-report. There was no relation between stress and unprotected anal intercourse. However, there was a relation between coping and unprotected anal intercourse. Subjects who reported unprotected anal intercourse used sex more of the time to help cope with stressful situations than did subjects who did not report unprotected anal intercourse. Unprotected anal intercourse was negatively associated with seeking social support and spiritual activities and positively associated with self-controlling coping, which involves keeping one's feelings to oneself, and positive reappraisal. The findings suggest that social aspects of coping may be a key to understanding differences between those who engage in high-risk sexual behavior and those who do not. Key words: coping, stress, AIDS, risk behavior
The present study used a cognitive theory of stress and coping (Lazarus & Folkman, 1984) to examine the relations between stress, coping processes, and high-risk sexual behavior in a sample of gay and bisexual men living in San Francisco. Because coping may be amenable to change, evidence of a relation between high-risk sexual behavior and the ways people cope with stress would have important implications for interventions to reduce risk of transmission of human immunodeficiency virus (HIV). Previous research has examined high-risk sexual behavior from the perspective of traditional health belief models that focus on perceived lack of susceptibility to infection and efficacy beliefs regarding the use of condoms (Huang, Watters, & Case, 1988; Joseph et al., 1987). The AIDS risk-reduction model (ARRM) explains the practice of high-risk sexual behavior specifically within the context of HIV infection by incorporating health belief variables and variables specific to sexual behavior and HIV disease, such as enjoyment of sexual practice and personal contact with individuals with AIDS (Catania et al., in press; Catania, Kegeles, & Coates, 1990). Other predictors of risk behaviors that have been identified include AIDS-specific health locus of control, peer norms, risk-behavior knowledge, being young, and drugs and alcohol (Ekstrand & Coates, 1990; Joseph et al., 1987; Kelly et al., 1990; McCusker et al., 1990). That sexual behavior may also be associated with stress and coping processes was suggested by McKusick, Horstman, and
Requests for reprints should be sent to Susan Folkman, Center for AIDS Prevention Studies, Suite 600, 74 New Montgomery, San Francisco CA 94105.
Coates (1985), who found that the risky sexual behavior of having three or more partners during the prior month was related to self-reports of sex to relieve tension. Despite the fact that sexual behavior may help some individuals reduce tension and feel better for the moment, if the sexual behavior includes unsafe practices, it is ultimately a maladaptive form of coping because it places the individual and his or her partners at risk for HIV transmission. The interpretation of high-risk sexual behavior as a coping response to stress is similar to interpretations offered for other risk behaviors such as the use of cigarettes, opiates, and alcohol. Chesney (1988) pointed out that smoking cessation programs traditionally place an emphasis on breaking the smoking "habit" without recognizing that smoking may be serving a coping function. She suggested that environmental stress provokes negative mood states such as depression, anxiety, and anger in the person undergoing stress, which in turn elicit coping responses, including maladaptive ones such as smoking. Alexander and Hadaway (1982) wrote of an adaptive orientation of opiate addiction, which is "an attempt to adapt to chronic distress of any sort through habitual use of opiate drugs" (p. 367). Wills and Shiffman (1985) characterized substance abuse as a response to coping that is ineffective in resolving stressful problems. Stone, Lennox, and Neale (1985) viewed alcohol use from a similar perspective. In the present study, we investigated high-risk sexual behavior from the perspective of a cognitive theory of stress and coping (Lazarus & Folkman 1984). According to this theory, a stressful situation is defined as one appraised by a person as personally significant to his or her well-being and as taxing or exceeding his or her resources. Coping is defined as thoughts and behaviors used by the person to manage or alter the problem causing distress (problem-
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COPING AND HIGH-RISK SEXUAL BEHAVIOR focused coping) and regulate the emotional response to the problem (emotion-focused coping; Lazarus & Folkman, 1984). Problem-focused coping, for example, includes behavioral and cognitive strategies for planful problem-solving and conflict resolution. Emotion-focused coping includes behavioral and cognitive strategies for escape-avoidance, distancing, keeping one's feelings to oneself, seeking emotional support, and reappraising the situation in a positive light. Reliance on spiritual beliefs and engaging in spiritual activities have been identified as ways of coping with stressful situations (Conway, 1985-1986; Ell & Haywood, 1985-1986; Lazarus & Folkman 1984; Pargament, 1990). Some people rely on spiritual beliefs to help with problem solving (e.g., to obtain guidance in decision making), and others use spiritual beliefs so as to come to terms with uncontrollable conditions, such as pain or loss (Ell & Haywood, 1985-1986; Pargament, 1990). The former could be considered problem-focused coping, and the latter could be considered emotion-focused coping. This study evaluated the extent to which stress, diverse forms of coping (self-controlling coping, escape—avoidance, distancing, planful problem-solving, seeking social support, and positive reappraisal), religious beliefs, and religious activities distinguish gay and bisexual men who report having unprotected anal intercourse from those who report not having unprotected anal intercourse.
METHOD Subjects The data we report are from the AIDS Behavioral Research Project (McKusick, Coates, Morin, Pollack, & Hoff, 1990). Gay and bisexual men were recruited in 1983 and 1984 at bathhouses and bars, and through advertisements seeking individuals who were in committed relationships or who did not use bathhouses or bars. Seven hundred fifty-four men enrolled in the sample in 1984, representing 51% of those approached to participate. Age of respondents in 1984 ranged from 19 to 63 years (M = 35.7 years, SD = 8.37 years). The majority of the sample in 1984 were in professional or white-collar occupations (77%), were White (91%), and had attended some college (68%). Mean annual income was $24,000. Subjects had been mailed a self-administered questionnaire each year. At the fifth annual data collection (November 1988), 71% (n = 575) of the original cohort completed and returned the questionnaire. Another 8% (n - 61) were known to have died (either through the report of their friends or through matching in the California Death Registry). Five hundred eight (67.4% of the original sample) men returned every questionnaire between 1984 and 1988. Only those respondents who were nonmonogamous in 1988 were included in the present analysis. Three hundred ninety-eight respondents met this criterion. Monogamous respondents were not included because unsafe sex practiced within a monogamous relationship is less risky than unsafe sex practiced between nonmonogamous partners (cf. McKusick et al., 1990). Measures With the exception of high-risk sexual behavior, which has been assessed in each of the annual surveys of the AIDS Behavioral Research Project, the variables in this study were included only in
the fifth annual survey. High-risk sexual behaviorwas defined as unprotected (receptive or insertive) anal intercourse, including withdrawal before ejaculation. Due to its skewed distribution, the variable was scored dichotomously according to whether the subject had engaged in unprotected anal intercourse during the previous month. We chose unprotected anal intercourse (receptive or insertive) as the dependent variable due to its proven relation with seroconversion (Detels et al., 1989; Goedert, 1987; Winkelstein et al., 1987). Although unprotected receptive anal intercourse carries a higher risk of infection than unprotected insertive anal intercourse, unprotected insertive anal intercourse still puts the person at 4.4 times the risk of HIV infection compared to a person who engages in no anal-genital intercourse (Detels et al., 1989). Subjects were categorized as having practiced this behavior if they reported one or more episodes of anal intercourse without a condom in the previous month with either a primary or a secondary partner. Stress was measured with a 10-item scale—developed for this study—that asked the subject to indicate, on a 4-point Likert scale ranging from none (0) to a great deal (3), the amount of stress he had experienced during the previous month in each of 10 domains (primary relationship, relationships with friends, relationships with family, work, finances, illnesses of close others, death of close others, own health, political issues, gay-related discrimination). Ratings were summed to create a total stress score. Coping was assessed with a shortened, 19-item version of the Ways of Coping Questionnaire (Folkman & Lazarus, 1980,1988). Subjects were asked to rate, on 4-point Likert scales ranging from not at all (0) to most of the time (3), the extent to which they used each item in coping with the most stressful domain of their life. This version of the Ways of Coping Questionnaire assessed six forms of coping: self-controlling coping (keeping one's feelings to oneself), escape-avoidance, distancing, planful problem-solving, seeking social support, and positive reappraisal. Six scores—one for each scale—were created by summing ratings. In addition, a single item asked subjects to rate, on a 4-point Likert scale ranging from not at all (0) to most of the time (3), the extent to which they used sex to help cope with stress. Spiritual beliefs were assessed with four items that were developed by the Berkeley Stress and Coping Project (Folkman, Lazarus, Gruen, & DeLongis, 1986) and modified for the present study ("Meditation/prayer helps me to find solutions to my problems," "Believing in a higher self/God gives meaning to my life," "Meditating/praying makes me feel better," and "Events in my life reflect an overall purpose and plan"). Subjects indicated, on 4-point Likert scales ranging from disagree strongly (1) to agree strongly (4), the extent to which they agreed with each item. Ratings were summed to create a spiritual beliefs score. Spiritual activities were assessed by asking subjects how often they engaged in five spiritual activities (attend religious or spiritual services, do personal meditation, read spiritual or metaphysical literature, talk to others about spiritual concerns, and consult a spiritual or religious leader). Ratings (0 = never, 4 = daily) were summed to create a spiritual activities score.
RESULTS The means and standard deviations of the measures of stress, coping, spiritual beliefs, and spiritual activities are shown in Table 1. The
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alpha coefficients for the coping scales are consistent with those in the literature. There was a possibility that HIV antibody status and disease status might be related to unprotected anal intercourse. Such relations, if significant, would make it difficult to interpret findings about the relations between stress, coping, spiritual beliefs and activities, and unprotected anal intercourse. Two hundred seventy-four subjects reported their serostatus. We found no relation between HIV antibody status and having unprotected anal intercourse (%2 = .35, p = TABLE 1 Means, Standard Deviations, and Alphas of Study Variables Variable Stress Self-controlling coping Planful problem-solving Seek social support Positive reappraisal Escape-avoidance Distancing Spiritual beliefs Spiritual activities Using sex to cope
Number of Items
Range
M
SD
a
10 3 3 3 2 4 3 4 5 1
0to25 Oto 9 Oto 9 Oto 9 Oto 6 Oto 12 Oto 8 Oto 12 Oto 20 Oto 3
10.69 4.19 5.05 4.43 3.22 3.45 3.04 10.41 5.34
4.63 2.04 1.83 1.93 1.44 2.26 1.84 3.86 4.37
.77
.83
.65 .63 .59 .69 .56 .53 .57 .90 .83 —
.55) among these subjects. Therefore, antibody status was not included as a control variable in the analysis. We also examined the relation between being diagnosed with AIDS and having unprotected anal intercourse. None of the 31 subjects diagnosed with AIDS reported unprotected anal intercourse. Because there was no variance among subjects with AIDS in the dependent variable of having unprotected anal intercourse, these subjects were excluded from subsequent analysis. One additional subject was missing data on this variable and was excluded. Therefore, the sample consisted of 366 mutually nonmonogomous men without a diagnosis of AIDS. Of the 10 domains of their lives that subjects rated for stressfulness, work-related stress was rated as most stressful, and stress associated with primary relationships was least stressful. The means of the 10 domains, ranked in order, are shown in Table 2. The single item that asked subjects the extent to which they used sex to help cope with stress was analyzed separately from the other predictor variables because its content (sexual behavior) overlapped with the variable of unprotected anal intercourse. Subjects who engaged in unprotected anal intercourse during the previous month reported using sex to cope with stress more of the time than did subjects who did not engage in unprotected anal intercourse; on a scale ranging from not at all (0) to most of the time (3), the mean for the unprotected group was 1.02, and the mean for the protected group was .73, f(358) = -2.90, p = .004. Stress, Coping, Spiritual Beliefs and Activities, and Unprotected Anal Intercourse
TABLE 2 Rank Order of Stressfulness of Life Domains Rank
Domain
M
1 2 3 4 5 6 7.5 7.5 9 10
Work Finances Illnesses of close others Political issues Monitoring own health Friends Death of close others Family Gay-related discrimination Primary relationship
1.61 1.36 1.34 1.30 1.11 .90 .86 .45
We used discriminant analysis to describe the relation between stress, coping, spiritual beliefs and activities on the one hand and unprotected anal intercourse on the other. Our goal was to identify variables that discriminated between those who reported they had had unprotected anal intercourse during the previous month and those who reported they had not had unprotected anal intercourse during the previous month. Data were missing for 35 subjects, leaving 331 subjects in the analysis. The covariance matrices were homogeneous (Box's M = 53.55,/? = .24). Prior probability of group membership was adjusted based on the data indicating that 76% of the subjects reported they had not had unprotected anal intercourse during the previous month (see Dunteman, 1984). The results of the discriminant analysis including all variables are shown in Table 3.
TABLE 3 Relations Between Coping, Spiritual Beliefs and Activities, and Protected and Unprotected Anal Intercourse
Variable Self-controlling* Spiritual activities* Seek social support* Positive reappraisal* Distancing Problem solving Escape-avoidance Spiritual beliefs Stress
Correlation With Discriminant Function .66 -.54 -.40 -.05 .36 .29 .28 -.22 -.14
Anal Standardized Discriminant Function .58 .67 .32 .34 .02 .24 .21 .22 .26
Note. Discriminant analysis: Wilks's X = .94, Bartlett's x 2 (9) = 19.05, p = .02. a n = 250. hn = 81. •Significant (p < .05) reduction in Wilks's lambda upon entry.
Intercourse
Protected*
Unprotected*
M
SD
M
SD
Am
2.00 4.56 1.90 1.42 1.85 1.86 2.30 3.86 4.62
4.79 4.28 4.04 3.23 3.30 5.27 3.74 10.00 10.43
2.19 3.66 2.05 1.45 1.78 1.76 2.28 3.91 4.60
5.62 4.50 3.19 2.92 4.96 3.38 10.48 10.82
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A stepwise procedure indicated that four of the variables were statistically significant and classified subjects into one of the two mutually exclusive groups with 77.8% accuracy, F(4, 326) = 4.21, p = .002 (eigenvalue = 16.47, p = .003). Of these four variables, spiritual activities and seeking social support were associated with membership in the group that reported no unprotected anal intercourse, whereas positive reappraisal and self-controlling coping were associated with membership in the group that reported unprotected anal intercourse.
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Coping and Spiritual Activities and Sexual Abstinence To rule out the possibility that coping and spiritual beliefs and activities associated with not engaging in unprotected anal intercourse were associated with abstaining from all sexual activities (i.e., oral-genital contact, oral-anal contact, anal intercourse with a condom, fisting, and mutual masturbation), we compared those who reported sexual activity other than unprotected anal intercourse (n = 278) with those who abstained from sexual activity (n = 53) during the previous month on stress, coping, spiritual beliefs, and spiritual activities. A multivariate analysis of variance indicated no significant difference between the two groups, F(9, 321) = .61.
DISCUSSION This study investigated the high-risk sexual behavior of unprotected anal intercourse from the perspective of stress and coping theory. There was no direct relation between stress and unprotected anal intercourse. Of interest, however, is that there was a relation between the ways people cope with stress and high-risk sexual behavior. Unprotected anal intercourse was negatively associated with spiritual activities and seeking social support and positively associated with self-controlling coping and positive reappraisal. Unprotected anal intercourse was also positively associated with using sex to help cope with stress. The findings in the present study suggest that social aspects of coping may be a key to understanding differences between those who engage in high-risk sexual behavior to cope with stress and those who do not. People who did not engage in high-risk sexual behavior sought more social support to help them with stressful situations than did people who did engage in high-risk sexual behavior. People who did not engage in high-risk sexual behavior also participated in more spiritual activities than did people who engaged in high-risk sexual behavior. Three of the five items assessing spiritual activities involved social interactions including attending religious or spiritual services, talking to others about spiritual concerns, and consulting a religious or spiritual leader. A recent study by Catania et al. (in press), which found that informal social support for adopting safe sexual behavior was associated with always using condoms during anal intercourse, is consistent with these findings. The significance of the social aspect of coping in understanding high-risk behavior is further supported by the finding that people who engaged in high-risk sexual behavior relied more on self-controlling coping than did people who did not engage in high-risk sexual behavior. The items that were used to assess self-controlling coping include "Kept my feelings to myself," "Tried to keep my feelings from interfering with other things too much," and "Tried to
keep others from knowing how bad things are." Conversations with sexual partners about unsafe sex can be extremely sensitive. People who cope by keeping their feelings to themselves may find it difficult to have conversations about unsafe sex to the extent that these conversations involve sharing fears and concerns about risk of HIV infection. Unlike the other forms of coping associated with high-risk sexual behavior, positive reappraisal is not interpersonal. Positive reappraisal is a form of cognitive restructuring that involves selectively attending to the positive aspects of a situation. Examples of positive reappraisal coping strategies include "I changed or grew as a person in a good way" and "I came out of the experience better than when I went in." Its association with high-risk behavior in this study suggests that it may facilitate the avoidance of threatening thoughts or information having to do with risk of HIV infection. The interpretation of the findings of this study is limited by certain of its features. Because the study is cross-sectional, causal relations among stress, coping, and high-risk sexual behavior cannot be evaluated. The method used to assess coping did not assess stable styles of coping, but rather how the person coped with a specific domain of his life. Previous research has demonstrated that people vary their coping depending on the demands and constraints of the situations they encounter (Folkman & Lazarus, 1980; Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986). As such, the single assessment of coping that was used in this study is a less reliable estimate of coping than had we been able to assess coping in diverse contexts. Further, two forms of coping—confrontational coping and self-blame—were not assessed due to space limitations in the survey instrument. Despite the limitations of the present study, the findings demonstrate that a stress and coping model is helpful in understanding high-risk sexual behavior. In particular, the study suggests that being socially involved with others—either by participating together in activities or seeking social support—is associated with not engaging in the high-risk behavior of unprotected anal intercourse. An important implication of this finding is that we may be able to provide safer, more adaptive coping options to people who rely on sex to cope with stress by teaching them socially oriented coping skills. An important next step is to determine whether high-risk sexual behavior can be reduced or prevented by teaching these skills.
ACKNOWLEDGMENTS This research was supported by National Institute of Mental Health (NIMH)/National Institute on Drug Abuse AIDS Center Grant MH42459 and NIMH Grant RO1 MH44045. We thank Linda Collette for her assistance with the data analysis.
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Chesney, M. A. (1988, October). Women, work-related stress and smoking. Paper presented at the Wennergren Center Foundation and MacArthur Foundation Women, Work, and Health Symposium, Stockholm. Conway, K. (1985-1986). Coping with the stress of medical problems among Black and White elderly. International Journal of Aging and Human Development, 21, 39-48. Detels, R., English, P., Visscher, B. R., Jacobsen, L., Kingsley, L. A., Chmiel, J. S., Dudley, J. P., Eldred, L. G., & Ginzburg, H. M. (1989). Seroconversion, sexual activity, and condom use among 2915 seronegative men, followed for up to 2 years. Journal ofAIDS, 2, 77-83. Dunteman, G. H. (1984). Introduction to multivariate analysis. Beverly Hills, CA: Sage. Ekstrand, M. L., & Coates, T. J. (1990). Maintenance of safer sexual behaviors and predictors of risky sex: The San Francisco Men's Health Study. American Journal of Public Health, 80, 973-977. Ell, K. O., & Haywood, J. L. (1985-1986). Sociocultural factors in MI recovery: An exploratory study. International Journal of Psychiatry in Medicine, 15, 157-175. Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middleaged community sample. Journal of Health and Social Behavior, 21, 219-239. Folkman, S., & Lazarus, R. S. (1988). The Ways of Coping Questionnaire. Palo Alto, CA: Consulting Psychologists Press. Folkman, S., Lazarus, R. S., Dunkel-Schetter, C , DeLongis, A., & Gruen, R. (1986). The dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. Journal of Personality and Social Psychology, 50, 992-1003. Folkman, S., Lazarus, R. S., Gruen, R., & DeLongis, A. (1986). Appraisal, coping, health status, and psychological symptoms. Journal of Personality and Social Psychology, 50, 571-579. Goedert, J. J. (1987). What is safe sex? Suggested standards linked to testing for human immunodeficiency virus. New England Journal of Medicine, 316,1339-1342. Huang, K. H. C , Watters, J. K., & Case, P. (1988, October). Health beliefs and self-efficacy: Predictors of safer needle use and safer sex among intravenous drug users. Paper presented at the meeting of the American
Public Health Association, Boston. Joseph, J. G., Montgomery, S. B., Emmons, C , Kessler, R. C , Ostrow, D. G., Wortman, C. B., O'Brien, K., Eller, M., & Eshleman, S. (1987). Magnitude and determinants of behavioral risk reduction: Longitudinal analysis of a cohort at risk for AIDS. Psychology and Health, 1, 73-96. Kelly, J. A., St. Lawrence, J. S., Brasfield, T. L., Lemke, A., Amidei, T., Roffman, R. E., Hood, H. V., Kilgore, H., Smith, J. E., & McNeill, C, Jr. (1990). Psychological factors that predict AIDS high-risk versus AIDS precautionary behavior. Journal of Consulting and Clinical Psychology, 58, 117-120. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. McCusker, J., Westenhouse, J., Stoddard, A. N., Zapka, J. G., Zorn, M. W., & Mayer, K. H. (1990). Use of drugs and alcohol by homosexually active men in relation to sexual practices. Journal of Acquired Immune Deficiency Syndromes, 3, 729—736. McKusick, L. M., Coates, T. J., Morin, S. F., Pollack, L., & Hoff, C. (1990). Longitudinal predictors of reductions in unprotected anal intercourse among gay men in San Francisco: The AIDS Behavioral Research Project. American Journal of Public Health, 80, 978-983. McKusick, L., Horstman, W., & Coates, T. J. (1985). Aids and sexual behavior reported by gay men in San Francisco. Journal ofPublic Health, 75, 493^96. Pargament, K. I. (1990). God help me: Toward a theoretical framework of coping for the psychology of religion. Research in the Social Scientific Study of Religion, 2, 195-224. Stone, A. A., Lennox, S., & Neale, J. M. (1985). Daily coping and alcohol use in a sample of community adults. In S. Shiftman & T. A. Wills (Eds.), Coping and substance use (pp. 199-220). New York: Academic. Wills, T. A., & Shiftman, S. (1985). Coping and substance use: A conceptual framework. In S. Shiftman & T. A. Wills (Eds.), Coping and substance use (pp. 3-24). New York: Academic. Winkelstein, W., Samuel, M., Padian, N., Wiley, J. A., Lang, W., Anderson, R. E., & Levy, J. A. (1987). Reduction in human immunodeficiency virus transmission among homosexual/bisexual men: 1982-1986. American Journal of Public Health, 77, 685-689.
Stress, Coping, and High-Risk Sexual Behavior Susan Folkman Center for AIDS Prevention Studies and Division of General Internal Medicine University of California, San Francisco
Margaret A. Chesney
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Center for AIDS Prevention Studies and Department of Epidemiology and Biostatistics University of California, San Francisco
Lance Pollack and Connie Phillips Center for AIDS Prevention Studies We examined the relation between stress, coping, and a high-risk sexual behavior (unprotected anal intercourse) in 398 nonmonogamous gay and bisexual men from the AIDS Behavioral Research Project in San Francisco. Unprotected anal intercourse during the previous month, the amount of stress experienced during the previous month in each of 10 domains, six types of coping (self-controlling coping, escape-avoidance, distancing, planful problem-solving, seeking social support, and positive reappraisal), and spiritual beliefs and spiritual activities were assessed through self-report. There was no relation between stress and unprotected anal intercourse. However, there was a relation between coping and unprotected anal intercourse. Subjects who reported unprotected anal intercourse used sex more of the time to help cope with stressful situations than did subjects who did not report unprotected anal intercourse. Unprotected anal intercourse was negatively associated with seeking social support and spiritual activities and positively associated with self-controlling coping, which involves keeping one's feelings to oneself, and positive reappraisal. The findings suggest that social aspects of coping may be a key to understanding differences between those who engage in high-risk sexual behavior and those who do not. Key words: coping, stress, AIDS, risk behavior
The present study used a cognitive theory of stress and coping (Lazarus & Folkman, 1984) to examine the relations between stress, coping processes, and high-risk sexual behavior in a sample of gay and bisexual men living in San Francisco. Because coping may be amenable to change, evidence of a relation between high-risk sexual behavior and the ways people cope with stress would have important implications for interventions to reduce risk of transmission of human immunodeficiency virus (HIV). Previous research has examined high-risk sexual behavior from the perspective of traditional health belief models that focus on perceived lack of susceptibility to infection and efficacy beliefs regarding the use of condoms (Huang, Watters, & Case, 1988; Joseph et al., 1987). The AIDS risk-reduction model (ARRM) explains the practice of high-risk sexual behavior specifically within the context of HIV infection by incorporating health belief variables and variables specific to sexual behavior and HIV disease, such as enjoyment of sexual practice and personal contact with individuals with AIDS (Catania et al., in press; Catania, Kegeles, & Coates, 1990). Other predictors of risk behaviors that have been identified include AIDS-specific health locus of control, peer norms, risk-behavior knowledge, being young, and drugs and alcohol (Ekstrand & Coates, 1990; Joseph et al., 1987; Kelly et al., 1990; McCusker et al., 1990). That sexual behavior may also be associated with stress and coping processes was suggested by McKusick, Horstman, and
Requests for reprints should be sent to Susan Folkman, Center for AIDS Prevention Studies, Suite 600, 74 New Montgomery, San Francisco CA 94105.
Coates (1985), who found that the risky sexual behavior of having three or more partners during the prior month was related to self-reports of sex to relieve tension. Despite the fact that sexual behavior may help some individuals reduce tension and feel better for the moment, if the sexual behavior includes unsafe practices, it is ultimately a maladaptive form of coping because it places the individual and his or her partners at risk for HIV transmission. The interpretation of high-risk sexual behavior as a coping response to stress is similar to interpretations offered for other risk behaviors such as the use of cigarettes, opiates, and alcohol. Chesney (1988) pointed out that smoking cessation programs traditionally place an emphasis on breaking the smoking "habit" without recognizing that smoking may be serving a coping function. She suggested that environmental stress provokes negative mood states such as depression, anxiety, and anger in the person undergoing stress, which in turn elicit coping responses, including maladaptive ones such as smoking. Alexander and Hadaway (1982) wrote of an adaptive orientation of opiate addiction, which is "an attempt to adapt to chronic distress of any sort through habitual use of opiate drugs" (p. 367). Wills and Shiffman (1985) characterized substance abuse as a response to coping that is ineffective in resolving stressful problems. Stone, Lennox, and Neale (1985) viewed alcohol use from a similar perspective. In the present study, we investigated high-risk sexual behavior from the perspective of a cognitive theory of stress and coping (Lazarus & Folkman 1984). According to this theory, a stressful situation is defined as one appraised by a person as personally significant to his or her well-being and as taxing or exceeding his or her resources. Coping is defined as thoughts and behaviors used by the person to manage or alter the problem causing distress (problem-
219
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COPING AND HIGH-RISK SEXUAL BEHAVIOR focused coping) and regulate the emotional response to the problem (emotion-focused coping; Lazarus & Folkman, 1984). Problem-focused coping, for example, includes behavioral and cognitive strategies for planful problem-solving and conflict resolution. Emotion-focused coping includes behavioral and cognitive strategies for escape-avoidance, distancing, keeping one's feelings to oneself, seeking emotional support, and reappraising the situation in a positive light. Reliance on spiritual beliefs and engaging in spiritual activities have been identified as ways of coping with stressful situations (Conway, 1985-1986; Ell & Haywood, 1985-1986; Lazarus & Folkman 1984; Pargament, 1990). Some people rely on spiritual beliefs to help with problem solving (e.g., to obtain guidance in decision making), and others use spiritual beliefs so as to come to terms with uncontrollable conditions, such as pain or loss (Ell & Haywood, 1985-1986; Pargament, 1990). The former could be considered problem-focused coping, and the latter could be considered emotion-focused coping. This study evaluated the extent to which stress, diverse forms of coping (self-controlling coping, escape—avoidance, distancing, planful problem-solving, seeking social support, and positive reappraisal), religious beliefs, and religious activities distinguish gay and bisexual men who report having unprotected anal intercourse from those who report not having unprotected anal intercourse.
METHOD Subjects The data we report are from the AIDS Behavioral Research Project (McKusick, Coates, Morin, Pollack, & Hoff, 1990). Gay and bisexual men were recruited in 1983 and 1984 at bathhouses and bars, and through advertisements seeking individuals who were in committed relationships or who did not use bathhouses or bars. Seven hundred fifty-four men enrolled in the sample in 1984, representing 51% of those approached to participate. Age of respondents in 1984 ranged from 19 to 63 years (M = 35.7 years, SD = 8.37 years). The majority of the sample in 1984 were in professional or white-collar occupations (77%), were White (91%), and had attended some college (68%). Mean annual income was $24,000. Subjects had been mailed a self-administered questionnaire each year. At the fifth annual data collection (November 1988), 71% (n = 575) of the original cohort completed and returned the questionnaire. Another 8% (n - 61) were known to have died (either through the report of their friends or through matching in the California Death Registry). Five hundred eight (67.4% of the original sample) men returned every questionnaire between 1984 and 1988. Only those respondents who were nonmonogamous in 1988 were included in the present analysis. Three hundred ninety-eight respondents met this criterion. Monogamous respondents were not included because unsafe sex practiced within a monogamous relationship is less risky than unsafe sex practiced between nonmonogamous partners (cf. McKusick et al., 1990). Measures With the exception of high-risk sexual behavior, which has been assessed in each of the annual surveys of the AIDS Behavioral Research Project, the variables in this study were included only in
the fifth annual survey. High-risk sexual behaviorwas defined as unprotected (receptive or insertive) anal intercourse, including withdrawal before ejaculation. Due to its skewed distribution, the variable was scored dichotomously according to whether the subject had engaged in unprotected anal intercourse during the previous month. We chose unprotected anal intercourse (receptive or insertive) as the dependent variable due to its proven relation with seroconversion (Detels et al., 1989; Goedert, 1987; Winkelstein et al., 1987). Although unprotected receptive anal intercourse carries a higher risk of infection than unprotected insertive anal intercourse, unprotected insertive anal intercourse still puts the person at 4.4 times the risk of HIV infection compared to a person who engages in no anal-genital intercourse (Detels et al., 1989). Subjects were categorized as having practiced this behavior if they reported one or more episodes of anal intercourse without a condom in the previous month with either a primary or a secondary partner. Stress was measured with a 10-item scale—developed for this study—that asked the subject to indicate, on a 4-point Likert scale ranging from none (0) to a great deal (3), the amount of stress he had experienced during the previous month in each of 10 domains (primary relationship, relationships with friends, relationships with family, work, finances, illnesses of close others, death of close others, own health, political issues, gay-related discrimination). Ratings were summed to create a total stress score. Coping was assessed with a shortened, 19-item version of the Ways of Coping Questionnaire (Folkman & Lazarus, 1980,1988). Subjects were asked to rate, on 4-point Likert scales ranging from not at all (0) to most of the time (3), the extent to which they used each item in coping with the most stressful domain of their life. This version of the Ways of Coping Questionnaire assessed six forms of coping: self-controlling coping (keeping one's feelings to oneself), escape-avoidance, distancing, planful problem-solving, seeking social support, and positive reappraisal. Six scores—one for each scale—were created by summing ratings. In addition, a single item asked subjects to rate, on a 4-point Likert scale ranging from not at all (0) to most of the time (3), the extent to which they used sex to help cope with stress. Spiritual beliefs were assessed with four items that were developed by the Berkeley Stress and Coping Project (Folkman, Lazarus, Gruen, & DeLongis, 1986) and modified for the present study ("Meditation/prayer helps me to find solutions to my problems," "Believing in a higher self/God gives meaning to my life," "Meditating/praying makes me feel better," and "Events in my life reflect an overall purpose and plan"). Subjects indicated, on 4-point Likert scales ranging from disagree strongly (1) to agree strongly (4), the extent to which they agreed with each item. Ratings were summed to create a spiritual beliefs score. Spiritual activities were assessed by asking subjects how often they engaged in five spiritual activities (attend religious or spiritual services, do personal meditation, read spiritual or metaphysical literature, talk to others about spiritual concerns, and consult a spiritual or religious leader). Ratings (0 = never, 4 = daily) were summed to create a spiritual activities score.
RESULTS The means and standard deviations of the measures of stress, coping, spiritual beliefs, and spiritual activities are shown in Table 1. The
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alpha coefficients for the coping scales are consistent with those in the literature. There was a possibility that HIV antibody status and disease status might be related to unprotected anal intercourse. Such relations, if significant, would make it difficult to interpret findings about the relations between stress, coping, spiritual beliefs and activities, and unprotected anal intercourse. Two hundred seventy-four subjects reported their serostatus. We found no relation between HIV antibody status and having unprotected anal intercourse (%2 = .35, p = TABLE 1 Means, Standard Deviations, and Alphas of Study Variables Variable Stress Self-controlling coping Planful problem-solving Seek social support Positive reappraisal Escape-avoidance Distancing Spiritual beliefs Spiritual activities Using sex to cope
Number of Items
Range
M
SD
a
10 3 3 3 2 4 3 4 5 1
0to25 Oto 9 Oto 9 Oto 9 Oto 6 Oto 12 Oto 8 Oto 12 Oto 20 Oto 3
10.69 4.19 5.05 4.43 3.22 3.45 3.04 10.41 5.34
4.63 2.04 1.83 1.93 1.44 2.26 1.84 3.86 4.37
.77
.83
.65 .63 .59 .69 .56 .53 .57 .90 .83 —
.55) among these subjects. Therefore, antibody status was not included as a control variable in the analysis. We also examined the relation between being diagnosed with AIDS and having unprotected anal intercourse. None of the 31 subjects diagnosed with AIDS reported unprotected anal intercourse. Because there was no variance among subjects with AIDS in the dependent variable of having unprotected anal intercourse, these subjects were excluded from subsequent analysis. One additional subject was missing data on this variable and was excluded. Therefore, the sample consisted of 366 mutually nonmonogomous men without a diagnosis of AIDS. Of the 10 domains of their lives that subjects rated for stressfulness, work-related stress was rated as most stressful, and stress associated with primary relationships was least stressful. The means of the 10 domains, ranked in order, are shown in Table 2. The single item that asked subjects the extent to which they used sex to help cope with stress was analyzed separately from the other predictor variables because its content (sexual behavior) overlapped with the variable of unprotected anal intercourse. Subjects who engaged in unprotected anal intercourse during the previous month reported using sex to cope with stress more of the time than did subjects who did not engage in unprotected anal intercourse; on a scale ranging from not at all (0) to most of the time (3), the mean for the unprotected group was 1.02, and the mean for the protected group was .73, f(358) = -2.90, p = .004. Stress, Coping, Spiritual Beliefs and Activities, and Unprotected Anal Intercourse
TABLE 2 Rank Order of Stressfulness of Life Domains Rank
Domain
M
1 2 3 4 5 6 7.5 7.5 9 10
Work Finances Illnesses of close others Political issues Monitoring own health Friends Death of close others Family Gay-related discrimination Primary relationship
1.61 1.36 1.34 1.30 1.11 .90 .86 .45
We used discriminant analysis to describe the relation between stress, coping, spiritual beliefs and activities on the one hand and unprotected anal intercourse on the other. Our goal was to identify variables that discriminated between those who reported they had had unprotected anal intercourse during the previous month and those who reported they had not had unprotected anal intercourse during the previous month. Data were missing for 35 subjects, leaving 331 subjects in the analysis. The covariance matrices were homogeneous (Box's M = 53.55,/? = .24). Prior probability of group membership was adjusted based on the data indicating that 76% of the subjects reported they had not had unprotected anal intercourse during the previous month (see Dunteman, 1984). The results of the discriminant analysis including all variables are shown in Table 3.
TABLE 3 Relations Between Coping, Spiritual Beliefs and Activities, and Protected and Unprotected Anal Intercourse
Variable Self-controlling* Spiritual activities* Seek social support* Positive reappraisal* Distancing Problem solving Escape-avoidance Spiritual beliefs Stress
Correlation With Discriminant Function .66 -.54 -.40 -.05 .36 .29 .28 -.22 -.14
Anal Standardized Discriminant Function .58 .67 .32 .34 .02 .24 .21 .22 .26
Note. Discriminant analysis: Wilks's X = .94, Bartlett's x 2 (9) = 19.05, p = .02. a n = 250. hn = 81. •Significant (p < .05) reduction in Wilks's lambda upon entry.
Intercourse
Protected*
Unprotected*
M
SD
M
SD
Am
2.00 4.56 1.90 1.42 1.85 1.86 2.30 3.86 4.62
4.79 4.28 4.04 3.23 3.30 5.27 3.74 10.00 10.43
2.19 3.66 2.05 1.45 1.78 1.76 2.28 3.91 4.60
5.62 4.50 3.19 2.92 4.96 3.38 10.48 10.82
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A stepwise procedure indicated that four of the variables were statistically significant and classified subjects into one of the two mutually exclusive groups with 77.8% accuracy, F(4, 326) = 4.21, p = .002 (eigenvalue = 16.47, p = .003). Of these four variables, spiritual activities and seeking social support were associated with membership in the group that reported no unprotected anal intercourse, whereas positive reappraisal and self-controlling coping were associated with membership in the group that reported unprotected anal intercourse.
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Coping and Spiritual Activities and Sexual Abstinence To rule out the possibility that coping and spiritual beliefs and activities associated with not engaging in unprotected anal intercourse were associated with abstaining from all sexual activities (i.e., oral-genital contact, oral-anal contact, anal intercourse with a condom, fisting, and mutual masturbation), we compared those who reported sexual activity other than unprotected anal intercourse (n = 278) with those who abstained from sexual activity (n = 53) during the previous month on stress, coping, spiritual beliefs, and spiritual activities. A multivariate analysis of variance indicated no significant difference between the two groups, F(9, 321) = .61.
DISCUSSION This study investigated the high-risk sexual behavior of unprotected anal intercourse from the perspective of stress and coping theory. There was no direct relation between stress and unprotected anal intercourse. Of interest, however, is that there was a relation between the ways people cope with stress and high-risk sexual behavior. Unprotected anal intercourse was negatively associated with spiritual activities and seeking social support and positively associated with self-controlling coping and positive reappraisal. Unprotected anal intercourse was also positively associated with using sex to help cope with stress. The findings in the present study suggest that social aspects of coping may be a key to understanding differences between those who engage in high-risk sexual behavior to cope with stress and those who do not. People who did not engage in high-risk sexual behavior sought more social support to help them with stressful situations than did people who did engage in high-risk sexual behavior. People who did not engage in high-risk sexual behavior also participated in more spiritual activities than did people who engaged in high-risk sexual behavior. Three of the five items assessing spiritual activities involved social interactions including attending religious or spiritual services, talking to others about spiritual concerns, and consulting a religious or spiritual leader. A recent study by Catania et al. (in press), which found that informal social support for adopting safe sexual behavior was associated with always using condoms during anal intercourse, is consistent with these findings. The significance of the social aspect of coping in understanding high-risk behavior is further supported by the finding that people who engaged in high-risk sexual behavior relied more on self-controlling coping than did people who did not engage in high-risk sexual behavior. The items that were used to assess self-controlling coping include "Kept my feelings to myself," "Tried to keep my feelings from interfering with other things too much," and "Tried to
keep others from knowing how bad things are." Conversations with sexual partners about unsafe sex can be extremely sensitive. People who cope by keeping their feelings to themselves may find it difficult to have conversations about unsafe sex to the extent that these conversations involve sharing fears and concerns about risk of HIV infection. Unlike the other forms of coping associated with high-risk sexual behavior, positive reappraisal is not interpersonal. Positive reappraisal is a form of cognitive restructuring that involves selectively attending to the positive aspects of a situation. Examples of positive reappraisal coping strategies include "I changed or grew as a person in a good way" and "I came out of the experience better than when I went in." Its association with high-risk behavior in this study suggests that it may facilitate the avoidance of threatening thoughts or information having to do with risk of HIV infection. The interpretation of the findings of this study is limited by certain of its features. Because the study is cross-sectional, causal relations among stress, coping, and high-risk sexual behavior cannot be evaluated. The method used to assess coping did not assess stable styles of coping, but rather how the person coped with a specific domain of his life. Previous research has demonstrated that people vary their coping depending on the demands and constraints of the situations they encounter (Folkman & Lazarus, 1980; Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986). As such, the single assessment of coping that was used in this study is a less reliable estimate of coping than had we been able to assess coping in diverse contexts. Further, two forms of coping—confrontational coping and self-blame—were not assessed due to space limitations in the survey instrument. Despite the limitations of the present study, the findings demonstrate that a stress and coping model is helpful in understanding high-risk sexual behavior. In particular, the study suggests that being socially involved with others—either by participating together in activities or seeking social support—is associated with not engaging in the high-risk behavior of unprotected anal intercourse. An important implication of this finding is that we may be able to provide safer, more adaptive coping options to people who rely on sex to cope with stress by teaching them socially oriented coping skills. An important next step is to determine whether high-risk sexual behavior can be reduced or prevented by teaching these skills.
ACKNOWLEDGMENTS This research was supported by National Institute of Mental Health (NIMH)/National Institute on Drug Abuse AIDS Center Grant MH42459 and NIMH Grant RO1 MH44045. We thank Linda Collette for her assistance with the data analysis.
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