HEALTH EDUCATION RESEARCH Vol.13 no.3 1998 Theory & Practice Pages 317-330

Towards a psycho-social theoretical framework for sexual health promotion

Daniel Wight, Charles Abraham1 and Sue Scott2

Abstract Introduction

Numerous interventions have been designed to The threat of HTV highlighted the need to prepare promote safer sexual behaviour amongst young young people to manage competently the emotional people. However, relatively few have proved and biological challenges inherent in forming effective, which is, at least partially, due to romantic relationships, and living safe and satisfy- the lack of development of theoretically based ing sexual lives. These challenges are especially programmes. An understanding of the origins acute for young people living in a media-permeated and control of sexual behaviour can be derived society in which the commercialization of sexual from basic social science research. Unless this semiotics is commonplace. Sexual desire and is applied to the design of behaviour-change sexual relations are focal topics in the most popular programmes they are unlikely to target the and accessible newspapers, and in magazines and most important determinants of young people's other media designed for young people (McRobbie, sexual behaviour and are, therefore, unlikely to 1996; Wellings, 1996). be effective. This paper outlines some of the key The reported median age at first intercourse is theoretical insights which have been drawn falling in the UK, and currently 19% of 16- to 19- upon in the development of a new sex education year-old women and 28% of 16- to 19-year-old programme currently being tested in Scottish men report intercourse before 16 (Johnson et al., schools. The theoretical basis is intentionally 1994). Early sexual experiences are often unprotec- eclectic, combining social psychological cognit- ted and lead to unwanted pregnancies (Bury, 1984). ive models with sociological interpretations, These, in turn, may result in terminations and more since we are not concerned to advance any than 40 000 are performed on teenagers each year particular theory but to find which are most in the UK. Low rates of teenage condom use useful in promoting sexual health. First, the (Hingson et al, 1990; West et al, 1993) and social influences on sexual behaviour are consid- increasing rates of sexually transmitted diseases ered, and then the way in which these translate (STDs) amongst teenagers (Boyer and Kegeles, into individual perceptions and beliefs. Finally, 1991), including the slower decline in gonorrhoea the paper attempts to develop a theoretical amongst young people, and an increase in chlamy- understanding of sexual interaction and the dia and associated pelvic inflammatory disease social contexts of sexual behaviour. amongst young women in the UK (RCOG, 1991; HEA, 1994; SNAP, 1994), all underline the need for enhanced education to promote safer sex. MRC Medical Unit, 6 Lilybank Gardens, Numerous interventions have been designed to Glasgow G12 8RZ, 'School of Social Sciences, Arts Building, University of Sussex, Falraer, Brighton BN1 promote safer sexual behaviour amongst young 9QN and 2Department of Applied Social Sciences, people but relatively few have proved effective University of Stirling, Stirling FK9 4LA, UK (Fisher and Fisher, 1992). Oakley et al. (1995)

C Oxford University Press 317 D. Wight et al. judged 12 of 65 outcome evaluation studies to be theory-based interventions are being tested against methodologically sound and found only two which best current practice (e.g. Schaalma et al., 1996), showed clear evidence of a subsequent change in but even in such cases researchers can face pressure young people's sexual behaviour. One of these, a to make new materials immediately available to safer sex intervention for teenage runaways, found all. Research-based health promotion depends upon an increase in reported condom use and decreased resisting such pressures and gathering evidence risk behaviour (Rotheram-Borus etal., 1991), while which, in the case of effective interventions, will the other reported that a programme designed provide a strong argument for future investment. to promote sexual abstinence increased sexual Co-operation between social scientists and health initiation amongst young men (Christopher and promotion practitioners may be particularly pro- Roosa, 1991). It should be noted, however, that ductive in the development of school-based sex some programmes demonstrated to be effective education programmes where a growing body of were excluded from Oakley et al.'s review because evidence suggests that theory-based programmes their evaluation reports did not meet the exacting are more effective than routine practice. Schaalma methodological criteria or because results had not et al. (1996) report greater belief changes and yet been published (e.g. Jemmott et al., 1992; differential behaviour change amongst those most Walter and Vaughan, 1993; Schaalma etal., 1996). at risk, as a result of participating in a theory-based This failure to develop effective interventions programme compared to routine sex education in is, at least partially, due to the lack of theoretically schools in The Netherlands. Mellanby et al. (1995) based programme development. Fisher and Fisher report on the success of a similar programme in the (1992), for example, noted that interventions based UK and, in a review of school-based programmes, on formal conceptualizations of any kind were Kirby et al. (1994) note that a basis in social- 'exceedingly rare' (p. 463). Unless an understand- cognitive theory is one of nine features which ing of the origins and control of sexual behaviour, distinguish effective programmes from ineffect- which can be derived from basic social science ive ones. research, is applied to the design of behaviour- The aim of this paper is to outline some of the change programmes, these programmes are key theoretical insights which have been drawn unlikely to target the most important determinants upon in the development of a new sex education of young people's sexual behaviour and are, there- programme (Dixon et al., 1996) currently being fore, unlikely to be effective. tested in Scottish schools (Wight, 1997). The broad Kok and Green (1990) have called for greater aims of the programme are: co-operation between social scientists and health (1) To improve the quality of young people's promotion practitioners, but also noted how the sexual relationships, particularly in terms of different priorities of practitioners and researchers reducing anxiety and regretted sexual beha- lead to a conflict of interests. Practitioners want to viours. make an immediate response to health education (2) To reduce the incidence of unsafe sex. needs and tend to rely on adaptations of current (3) To reduce the rate of unwanted pregnancies. practice, while researchers are keen to test carefully the validity and generalizability of their theories The theoretical basis is intentionally eclectic, before recommending applications. Furthermore, since we are not concerned to advance any particu- health promoters sometimes think, understandably, lar theory but to find which of the many available that they know what effective practice is and do are most useful in addressing the unwanted out- not see the benefit in further evaluative studies comes of sexual behaviour (see Kok, 1993). We when they have access to personal observations have highlighted and power issues relevant and feedback during the course of their own to young heterosexuals but, in general, the ideas practice. Co-operation should be possible where discussed below are not specific to any particular

318 A psycho-social theoretical framework for sexual health promotion . They are also applicable to a experiences. For many young women their intro- fairly wide age range, from 14 to at least 25 years duction to the world of sex is via reproduction and old, but we are paying particular attention to the specifically menstruation, an experience which is mid teens since this is the age group targeted in commonly problematic, stigmatizing and some- our intervention. We will consider first the social times painful (Prendergast, 1987; Laws, 1990). For influences on sexual behaviour, then the translation young men, no matter how problematic their entry of these into individual perceptions and beliefs, into 'manhood', there is the powerful social under- and finally the importance of understanding sexual standing that men are sexual creatures and that an interaction and the social contexts of sexual interest in sex is understandable, even expected. behaviour. For young women, on the other hand, sex is seen as potentially risky and overt interest in sex Social level influences continues to be seen in some sections of society as disrupting 'proper' feminine behaviour (Cowie Three main themes can be drawn from sociological and Lees, 1987), although certain features of pop- research on young people's sexuality. First, to a ular culture, such as advertising which presents great extent sexuality is learnt and leamt differently men as sex objects for women or the role models according to one's gender. Second, the management of sexually assertive women provided by the Spice of heterosexual relations depends upon culturally Girls, suggest that such values might be on the maintained and individually learnt gendered power wane. relations. Finally, the perception of health risk is This gulf between the way feminine and mascu- itself culturally defined. line sexualities develop is largely played out, and given meaning and individual specificity, in the Gender context of the separate social worlds which boys A fundamental understanding of sociology and and girls inhabit outside of their . This is social psychology is that sexuality is largely learnt, especially so during the years immediately prior rather than something purely innate of which we to early sexual relationships, in their early teens. become aware. Furthermore, for both biological Broadly speaking there is a clear class pattern and social reasons sexuality is learnt very differ- in this gender segregation, with it being more ently according to one's sex and gender (Jackson, pronounced in working class culture (Martin, 1982; Hawkes, 1996). 1981). Since sexual risk taking amongst the young Young men's first sexual experiences are usually is concentrated in die working class [or more solitary, involving masturbation, while young precisely, those with low levels of educational women's are with a partner (Gagnon and Simon, attainment (West et ai, 1993)] it is appropriate to 1974). In part this is probably due to boys' discus- focus on the implications of gender segregation sion of masturbation, but it is also probably con- even whilst acknowledging that these implications nected with boys' much greater familiarity with are not equally important across all social milieus. their genitals than girls, both because they are Boys' and girls' valuation of themselves is physically more obvious and because boys regu- shaped much more by the opinions of their own larly handle their penises to urinate. The radically sex than by those of the opposite sex (Gagnon and different initial sexual experiences of young men Simon, 1974). In this social world of same-sex and women is probably one important reason why groups contact with the opposite sex is young men tend to focus on genital pleasure and perhaps most valued as a key way of developing orgasm in sex, while for young women the meaning one's own (Wight, 1994). Further- of sex tends to be bound up with relationships. more, the development of is based These early experiences also relate to different on considerable prior identity formation so that we cultural assumptions which surround gender/body experience our bodies through meanings already

319 D. Wight et al. established in non-sexual areas of our lives, particu- cerns. Discussing sexual issues with the opposite larly gender roles (see Jackson, 1982). To put it sex should develop a greater understanding of simply, where conventional gender roles are the gendered perspectives and, hopefully, greater norm, young women experience sexual activity as respect for the ways in which the opposite gender a form of social service, while young men experi- views sexual relationships. Exercises involving ence it as a form of achievement (Gagnon and the development of scripts to express emotional Simon, 1974). This is borne out in the way young concern could facilitate heterosocial commitments, women describe their concerns that sex should whatever the participants' initial motivation (Gag- be satisfying for their partner, but show little non and Simon, 1974, p. 69): understanding of their own potential for sexual pleasure (Holland et al., 1992). Even when the young male's protestations of affection are cynical affectations to achieve Symbolic interactionism has shown how one's greater sexual access, what must be kept in identity emerges from an ongoing dialectic between mind is that we often become what we thought one's own presentation of oneself ('subjectively we were only pretending to be. appropriated identity') and one's audience's views of oneself ('objectively assigned identity') (Berger Probably the most important contribution a sex and Luckmann, 1966). For most young people education programme can make in promoting their sexual identities are primarily shaped by heterosociality is to go some way to de-sensitize interaction with same-sex peers, which makes their the discussion of sexual topics and develop explicit identities vulnerable to contact with the opposite verbal scripts for such conversations. Extending sex (Wight, 1994). This is particularly the case the world of speech into sexual encounters makes with young men, for whom sexual performance is communication on such practical issues as contra- of great importance, since in the dialectic between ception and sexual pleasure more likely and more an individual's asserted identity and the identity effective. This is especially important because his male peers assign to him there is little place available evidence suggests that those who discuss for observed reality. It is not surprising, therefore, protection with their partners are more likely to that young people should feel very anxious when use condoms (Boldero et al., 1992; Kashima et al., their sexual identities are to be challenged or 1993) and contraception more generally (Gold and confirmed for the first time by someone of the Berger, 1983; Polit-O'Hara and Kahn, 1985). Such opposite sex (Wight, 1994). discussion can disrupt those existing scripts which A central theme of sex education programmes discourage explicit consideration of sexual options might be to explore and question the ways in (Miller et al., 1993) or at best do little more than which young people's understanding of sexuality ensure that men and women communicate past and their sexual identities are formed predomin- each other (Gagnon and Simon, 1974; Jackson, antly through interaction with members of their 1996). It would also encourage young men to focus own sex. The broad aim of such a programme on their partner rather than their social status would be to move young people on from their amongst male peers, and encourage young women homosocial (same-sex) perspective to a more to reflect on their relative desire for sex and for heterosocial perspective, a development that, for romantic relationships. In short it should help to most, would take place anyway at some point in integrate feminine and masculine perspectives of the next 5-10 years. sexual relationships. There are various ways in which such a shift in In terms of young people's fragile sexual identit- perceptions might be facilitated. A programme ies, a sex education programme that involves the that enhanced young people's awareness of the sensible discussion of sex between young women homosocial concerns that shaped their own sexual and men will introduce opposite gender opinions identities would help them get beyond such con- into the identity assigned by others. When particip-

320 A psycho-social theoretical framework for sexual health promotion ants then enter heterosexual relationships they Young women, on the other hand, may think that should be rather more secure in their own identities they have a right to be sexual and sexually active, since these have already been modified and con- and even to have good sex, that is to be 'liberated', firmed, to some extent, by the opposite sex. but they also know the risks to their reputation of being seen as a 'slag' if they act on this knowledge Power (Lees, 1993; Kitzinger, 1995). Young women, then, Power can exist in sexual encounters in many find themselves in a situation in which to be ways. With respect to violence or its threat, there knowledgeable about sexual matters is to risk being is a need to understand the ways in which pressure seen as sexually knowing (i.e. experienced) in the can build along a continuum. Kelly (1988) context of a moral discourse which continues developed the notion of a continuum in relation to to shape cultural understandings of appropriate sexual violence in order to explicate both the femininity. common features which emerge in situations in This is further complicated by critiques of both which men exploit women and also the range 'traditional' constructions of sexuality as of more or less violent behaviour which may passive and reproductive, and a 'liberatory' dis- be entailed. course which renders women available for male Power, however, is not simply a zero sum game. sexual pleasure (Hollway, 1984). While these cri- It is not simply about dominance and does not tiques point to important aspects of gender and only operate at the individual level. Following power, in turn they produce what has been termed Foucault (1979) it can be argued that the nexus of a • 'protective' discourse which locates young power/knowledge operates at the level of discourse, women as victims of predatory male sexuality i.e. what is validated and what is reviled socially. (Thomson and Scott, 1991). This allows them little Power, in the context of sexuality, is neither space within which to define their own sexuality. simply about strength nor is it explicable through We would wish to argue, however, that power examination of the personal characteristics of indi- also engenders resistance (Foucault, 1981). Women vidual men, but is rooted in cultural positions are not simply passive victims of male power, as which validate men's desire and right to have sex, the women's movement and the development of and to understand their sexual urges as uncontrol- self help around violence against women illustrate. lable. The result of such biological readings of At the individual level women develop strategies bodily experiences and sexual practices at a social to deal with pressure and force, including leaving level is that individuals come to understand their the relationship. However, if young women are to sexuality through a biological lens which is difficult be 'empowered' to negotiate in relation to sex to occlude (Morgan and Scott, 1993). Thus if we within relationships they need to be enabled to are to enable young people to develop a sense of develop a sense of themselves as autonomous agency in relation to their sexuality we need to sexual actors. Knowledge is not sufficient and nor encourage them to be reflexive about how this is the desire to negotiate sexual safety without the biological perspective affects what is done in experiential basis to put this into practice. If young sexual contexts. women, in particular, are to be able to carry a Crucially, power, in heterosexual sexual encoun- sense of themselves across relationships then they ters, operates within the tensions produced by require the possibility of empowerment at both contradictory but co-existing discourses, i.e. the these levels: the intellectual and the experiential. 'moral' and the 'liberatory'. Men have power They need both knowledge and skills (Holland because they have, or are seen to have, knowledge et al., 1991, 1992). It seems likely that managing about sexuality and to hold such knowledge legit- safer sex in practice will depend upon sophisticated imately by virtue of their masculinity. An admission social negotiation involving personal goal setting, of ignorance can become a failure of masculinity. and the interactional micro-skills necessary to

321 D. Wight et al.

intervene successfully in and direct social sexual clear tension between a view of young people as encounters. being in need of knowledge in order to make For both young men and young women then, informed, mature, decisions and one which sees continuing to locate themselves within the domin- them as in need of protection from the adult world ant discourses of femininity and masculinity is for as long as possible. Anxieties about 'children' likely to prove an unsafe strategy in relation to and sexuality are not new, but the 19th century pregnancy, STDs and HTV. However, in so far as view was more likely to be of children as sinful, power operates more through the norms of feminine provocative and in need of governance, in contrast and masculine behaviour, rather than through to the late 20th century conception of them as imbalances in physical strength or actual know- innocent and in need of protection (Jackson, 1982). ledge, interventions can begin to address this However, both of these discourses of childhood by attempting to modify those norms through continue to co-exist in tension (Scott et al., 1997), encouraging reflection on both cultural and per- which produces contradictory views about sex sonal assumptions, and facilitating the development education. of alternative skills, strategies and understandings. We also live in an age which is characterized In short, by offering positive ways for young by a focus on individual identity and individual people to move beyond gender stereotypes in responsibility, and our understandings of risk are sexual interaction. Without this disruption of dom- closely related to identity (Bellaby, 1990; Giddens, inant discourses and practice safer sex promotion 1991; Adams, 1995). For instance, some people is unlikely to succeed. identify as risk takers, which is often a particular expression of masculine identity, while others high- Risk light particular risks to avoid as a means of Risk is a relatively modern concept, to a large establishing their social position (e.g. not having extent replacing older understandings of fate, which sex with 'slags'). The extent to which we concern can be understood as a means of managing hazards ourselves with risk is also related to how much of and insecurities which are seen by some to be our experience we attribute to fate or forces beyond particular to (Giddens, 1990; Beck, our control. 1992). Whereas life in the late 20th century would There are two common and competing dis- seem to be less hazardous for most people, this is courses around sexuality. On the one hand, sex is more real than apparent as we inhabit a culture construed as a secret and potentially dangerous which is increasingly sensitive to risk (Scott and activity, as itself fateful, in part as a result of being Williams, 1992; Scott and Freeman, 1995). Indeed, sequestered from other aspects of everyday life. our society has been said to be characterized by On the other hand, we are increasingly presented 'Risk Anxiety' (Beck, 1992). Understandings of with sex as a healthy leisure activity (Jackson and risk are, however, often culturally specific, varying Scott, 1996). The secret aspect of sexuality might with social context, age, gender, class, etc. Anxiet- possibly be part of its attraction, evidenced by ies accrete around particular groups and/or sets of high levels of adultery (Lawson, 1988) and hidden activities out of proportion to the material dangers commercial sexual activity. Young people grow up involved. receiving mixed messages: sex is everywhere, and Current sensitivities with regard to both young yet open and relaxed discussion of it is in most people and sexual activity are such examples. contexts highly problematic. When these foci of anxiety converge feelings tend For young women sex is associated with risks to run high as can be seen in the recurring debates to reputation and risk of pregnancy, and this, in about teenage pregnancy and sex education in addition to the view that an overt interest in sex schools, and in recent discussion about the explicit is unfeminine, locks young women into a romantic content of some 'teenage' magazines. There is a discourse in which trust and are mobilized

322 A psycho-social theoretical framework for sexual health promotion prophylactically in relation to sex (Scott and Free- first very ambitious for sexual health promotion. , 1995). If young women have to deal with However, encouraging young people to see situations in which sex is only deemed acceptable decision making about sex as a non-linear and, in the context of 'being in love', or at least in a ideally, a negotiated process would disrupt the 'steady' relationship, then these understandings of tendency to categorize oneself and others as risk the situation are more likely to be adopted. In turn, takers or non-risk takers according to rigid rules. this tends to entail defining the relationship as A parallel example is in relation to diet, where the being based on trust, which makes condom use tendency is to see a single chocolate as the end of less likely since it suggests risk (Holland et al., the diet and failure as license to eat. Thus not 1990). Young women may not see themselves as using a condom in one situation should not be actively taking risks, but as being caught up in a read as an inability to use condoms, but a specific situation where there are expectations which they failure in planning or negotiation which can prepare do not have the means to resist. On the other hand, the individual for more successful safer sexual they may well acknowledge the risks entailed but encounters in the future. Raising young people's be prepared to take them for the sake of love. awareness of the likelihood of lapses and why One key health promotion strategy in relation they may occur will not necessarily ensure 100% to unsafe sex has been to encourage talk between condom use, but is likely to result in greater partners about their sexual histories. Whereas for condom use than would be the case if individuals most young people this degree of openness is simply defined themselves as failed condom users. extremely hard to achieve (Ingham et al., 1991), If the harm reduction model is applied then any for those who are able to enter into such discussions safer sex is better than none. it may prove counter-productive. Talk about intim- ate matters is likely to produce intimacy which in Individual cognitions turn engenders trust which may increase risk taking (Scott and Freeman, 1995). Thus it is crucially At an individual level social and health psycholo- important that young people are not simply encour- gists have sought to map out how cultural influ- aged to talk to their partners about their sexual ences are translated into sets of socially shared histories, but are enabled to develop the skills to understandings, or cognitions, which vary between engage in communication that will result in reduced culture members and so account for different risk taking. Without such skills and the ability to perceptions and actions. For example, by character- reflect on the ways in which sexual interactions izing how susceptible individuals feel to a specified are shaped, in the wider context of gendered power health threat, psychologists can begin to categorize relations, young people are ill equipped to enter individuals in terms of their propensity to take into sexual negotiations. preventive action. Ideally sexual health promotion should prompt Subcultural differences may, of course, deter- participants to reflect on why some risks are mine the salience of particular beliefs and the acceptable and not others, and (to return to the implications they have for action. For example, previous theme) why risk taking is often context van der Velde and van der Pligt (1991) report specific. For instance, the presence of others from that higher perceived susceptibility to HIV was whom one seeks social approval can make all the positively related to intentions to use condoms difference between risk taking and avoidance: amongst their sample of heterosexuals with mul- greater awareness of this could lead people to tiple partners but negatively related to intentions predict, manage and/or avoid such situations (see amongst their sample of men, suggesting that below). further emphasis on personal susceptibility could Encouraging reflexivity in relation to sexual be counter-productive for the latter group. Sim- negotiation and decision making may seem at ilarly, Abraham et al. (1996) found that, although

323 D. Wight et al. young men's intentions to use condoms were ledging that those who are at risk are very like positively related to subsequent reports of condom oneself is the first step in accepting personal use, young women's intentions were not, sug- susceptibility (Weinstein, 1988). Attempts to dis- gesting a gender difference in the ability to translate tance HIV infection from 's sexuality condom-use intentions into action. were intended to highlight personal susceptibility These examples underline the need to determine amongst heterosexuals, but in this case prior cul- empirically the generalizability of relationships tural categories were so established there has been specified by cognitive models. However, this does limited success (Wight, 1993a). not detract from the observation that such self- report measures of individual cognitions can be Perceived benefits and barriers used to characterize individuals, within specified Actions which are thought to be effective, reward- cultural contexts, as being more or less likely to ing and having few costs are more likely to be engage in particular health-related behaviours. initiated. The perceived effectiveness of condom This, in turn, provides a basis for interventions use in relation to STD prevention has been largely which aim to alter cognitions which have been accepted (Abraham et al., 1992), but the high shown to be positively associated with preventive priority of contraception for many young people action amongst a particular target group (e.g. and the perceived relative ineffectiveness of con- Schaalma et al., 1996). If beliefs can be changed doms as contraceptives may undermine condom in a predictable manner and a corresponding shift use motivation. This recommends a message for in subsequent health behaviour is observed then combined contraceptive and condom use for the there is good reason to assume that effective health prevention of STDs/HIV, such as that used in promotion has been achieved by targeting theory- The Netherlands. Barriers to condom use include based cognitions. anticipated difficulties in relation to acquisition A series of 'social cognition' models or theories and concealment while carrying, loss of intimacy has been developed and tested (Conner and during use, awkwardness of use, anticipated loss Norman, 1996). Each model specifies a set of of pleasure during use and potential loss of social individual cognitions which have been shown to approval (Sherr, 1987; Abraham et al., 1992). motivate and regulate health behaviour, and we Some of these may be overcome by persuasive shall highlight a series of these which need to be communication or individual skills training, but considered in the design of safer sex programmes others require societal level interventions. For (Catania etal., 1990; Abraham and Sheeran, 1994). example, the cultural availability and acceptability of condoms will affect how likely young people Personal susceptibility to risk are to have a condom available when a sexual liaison occurs unexpectedly. Anticipated severe consequences of an event only threaten individuals who accept that they are per- sonally at risk (Weinstein, 1988; Sheeran and Social approval Abraham, 1996). Fear-inducing programmes are, Sexual interaction is inherently social, and often therefore, only likely to be effective if the audience involves mutual expression of affection, approval has already accepted that they are at risk. Personal and intimacy. It is, therefore, especially likely to susceptibility can be promoted by identifying and be affected by anticipated social approval and undermining stereotypes by which individuals dis- disapproval (Boyd and Wandersman, 1991; Jem- associate themselves from those they recognize to mott and Jemmott, 1991), and particularly that of be at risk. For example, the belief that those actual and potential sexual partners (Weisman infected with STDs have exceptionally high partner et al., 1991). Cognitions about social approval are turnovers or engage in distinctive sexual practices both individual beliefs that a person brings to a undermines personal susceptibility. Acknow- sexual encounter (e.g. that my partner will be

324 A psycho-social theoretical framework for sexual health promotion impressed if I produce a condom) and understand- you want and listening to others. By rehearsing ings that result from the immediate social inter- and planning young people can be better prepared action (e.g. that my partner is offended because I to deal with challenging social situations in which have produced a condom, judging by his/her face). they are likely to have little time for contemplation. Ensuring that young people are aware of their In particular they can be better prepared to interrupt peers' approval of safer sex, and of young people's non-verbal scripts through sensitization to relevant effective practice in protecting themselves, is likely situational and social cues. to reduce concerns about potential disapproval. The development of intentions can also be influenced by how individuals feel about an action. Perceived self-efficacy For example, if a person anticipates the regret Those who believe they have the ability success- s/he would subsequently feel if s/he did not take fully to undertake an action are more likely to an action (such as using a condom during sexual intend to take that action and more likely actually intercourse), s/he may be more likely to engage in to succeed, because they set themselves higher that behaviour (Richard et al., 1995). Alternatively, standards, exert more consistent effort and suffer an erotophobic individual is likely to avoid thinking less from stress-related disruptions during action about sex and therefore less likely to formulate (Bandura, 1992a,b). Perceived self-efficacy can be intentions to use condoms. This may also make her/ enhanced by careful explanation, by encourage- him feel uncertain and stressed in sexual situations. ment, by modelling actions, and by rehearsal and Rehearsal of the likely affective consequences practice. It is relatively easy to design self-efficacy of action and inaction may, therefore, influence enhancing exercises concerning the correct use of intentions and feelings during and prior to action. condoms. However, it is more challenging to Script analysis, video modelling and role play design self-efficacy enhancing exercises promoting are likely to be important to this kind of education. discussion of sexual desires and consequent behavi- For example, Schinke and Gordon (1992) describe ours with potential partners, friends and health a self-completion book using comic strip characters professionals (who may be important sources of and rap music verse to encourage effective action advice and resources). Yet, as we have noted above, regulation amongst young black people. This is a it is precisely these interaction management skills culturally-specific intervention using a game format which may be most important when preparing to facilitate the development of self-monitoring individuals successfully to manage their sexual cognitive skills and verbal resources which can encounters. Analysis of dialogue from sexual later be deployed to disrupt scripted sequences. A encounters, role play and visual modelling can all staged approach to negotiation is presented using be used to promote self-efficacy in relation to the acronym SODAS; stop, options, decide, act sexual discussion and negotiation. and self-praise. The first step, 'stop', explicitly elicits anticipated regret ('stop and think what Intentions and plans and scripts these choices could really mean for you today, The translation of intentions into action has been tomorrow...and for years to follow'). shown to depend upon the development of detailed and realistic plans which allow the individual to Focusing on the interaction specify how, where and when an action is to be carried out (Bagozzi, 1992; Gollwitzer, 1993). An individual's understanding of the issues and Consequently, an important aspect of self-efficacy her/his social skills are the bases of skilled social enhancement will be a realistic appraisal of how interaction; by developing relevant individual cog- the relevant social situations unfold (e.g. who is nitions young people can be empowered to manage likely to say what) and what opportunities exist sexual negotiation more competently. However, for taking and losing control, insisting on what knowing which cognitions should be the targets

325 D. Wight et al. of sex education programmes and what type of sed in advance of first sexual intercourse within a rehearsal and social skills training will be most relationship (Wight, 1993b). The recurrent phrase effective depends upon social psychological and reported in qualitative research is that it 'just sociological analyses of the types of interaction happened'. The value of planning and rehearsing which lead to safe and risky sexual encounters. has been discussed above. This will enable people to recognize social cues and allow them to fall Perceived benefits and social approval back on previously considered positions in rapidly When an individual assesses the benefits of an changing dialogue. While rehearsal of particular action prior to engaging in it, as discussed above, lines and approaches can be empowering, young social rewards and social costs are often especially people also need 'stop and think' strategies which important. Beliefs about what others think and do enable them to reconsider changing situations. can have an important impact on behaviour. While A clear illustration of how particular scripts can everyone brings such beliefs with them to a sexual empower participants in sexual negotiations is encounter, the interaction that then occurs is likely provided by research on prostitution. Bloor et al. to confirm or challenge such beliefs or introduce (1993) explain why female prostitutes take far entirely new ones. For instance, at the start of an fewer HIV risks than male prostitutes in their work encounter each partner is likely to have ideas about as a result of the negotiation around the encounter. which sexual behaviours are acceptable to the While female prostitutes usually negotiate the cost other, but their actions are likely to be rapidly of sexual acts explicitly prior to engaging in them, modified if their partner's body or verbal language male prostitutes tend to talk about payment after indicated something else. Cognitions modified by the event. This means that for the male prostitutes such interaction will then be part of the beliefs there is rarely the opportunity to negotiate whether each individual brings with them to their next anal sex will be protected or unprotected before sexual encounter, particularly if it is with the engaging in it. Awareness of the constraining same person. effects of social scripts and of the extent to which they can be altered is likely to be a prerequisite to Social support and joint planning enacting consistently prior plans and intentions in In addition to an individual's beliefs about what sexual negotiation. others do and want, her or his actions are directly Context of the encounter affected by other people through social support The nature of sexual negotiation is, at least partially, and joint planning or, alternatively, the absence of determined by the context in which the encounter these. This is especially important in the case of takes place. Behaviour can be shaped as much by co-operative behaviours such as condom use. While constraints of time or place (e.g. the return of perceived self-efficacy is likely to play an important or being seen in the park) as by the prior part in how well individuals manage such negoti- intentions or attitudes of the individuals involved. ation, whatever the particular attributes of the This makes it valuable to learn to predict risky individuals involved the outcome of sexual encoun- situations in order to prepare one's response, and ters is largely the result of the interaction that again underlines the importance of a comprehens- occurs at the time and the context within which ive consideration of a variety of scripts and strat- the encounter takes place. Thus individuals' scripts egies perhaps to delay decision making and may be easily disrupted by partners introducing certainly to maintain joint involvement in decision- new factors into the situation (see Schutz, 1970, making processes. for a theoretical analysis of such micro-interaction). In Britain less than a quarter of young people Maintaining ambiguity planned their first sexual intercourse (Johnson An important aspect of sexual negotiation which et al., 1994) and contraception is often not discus- needs to be highlighted in work seeking to empower

326 A psycho-social theoretical framework for sexual health promotion young people in sexual negotiation is the way both Conclusion partners often strive to maintain ambiguity about their intentions at the start of a relationship (Kent Until recently few sexual health programmes were et al., 1990). This does not apply with explicitly theoretically based and those that were relied predatory males, but with others their wish to have almost exclusively on social cognitive theory. This a relationship involving sexual intercourse is often paper is intended to summarize the main findings concealed in order to maintain their dignity should on the origins and control of sexual behaviour the wish not be mutual. For young women, not derived from basic social science research, in order declaring intent may be crucial to maintaining both to target the most important determinants of sexual reputation and the discourse of in which behaviour. We hope the paper will contribute to being 'swept away' can be seen as a justification the long process of translating theoretical insights for sex. Consequently the issue of condoms cannot from the social sciences into practical interventions. be raised until it is almost inevitable that sexual An eclectic range of theoretical insights has been intercourse will occur—usually at too late a stage considered in order to find which of the many to go and get one. Conversely, if one partner is available are most useful in addressing the explicit about his/her wish to have sex, it transforms unwanted outcomes of sexual behaviour. the interaction and allows for discussion of precau- Drawing on symbolic interactionism, phenom- tions. This not only allows for verbal control which enology and feminist analyses, recent sociological disrupts the non-verbal scripts, but also allows for research on young people's sexuality highlights social support in taking precautions. three key issues. First, our understanding of sexual- Subcultural norms ity is largely learnt and learnt differently according We have noted how others' approval is crucial. to one's gender. Being socially constructed it is, The identification of what is and is not approved of therefore, theoretically open to change. Second, within particular youth , and combining the outcome of heterosexual sexual encounters is safer sex messages within normative social inter- shaped by gendered power relationships. Third, action, is critical to the acceptability of safer sex the recognition and interpretation of health risks messages. Whether STD prevention, prolonging is culturally specific, varying with age, gender, the act of sexual intercourse or ensuring that one's social class, etc. partner is not anxious about pregnancy is the most Gender relations, power and risk are key aspects persuasive reason for using a condom may depend of our sexual worlds, but none is immutable. Young upon gender and specific subcultural norms. This people are capable of reflecting on their social underlines how important it is to draw on young and sexual practice, and need to be given the people's own awareness of what is acceptable and opportunity to do so in a context where they are powerful for them within their own social reality. under no immediate pressure but where they can Interventions might aim to make people more come to understand and deal with different points aware of the kind of interaction that occurs in of view, especially with regard to gender. sexual encounters and so enable them to predict At an individual level social cognition models and recognize situations in which they would be have sought to identify those cognitions which more likely to take sexual risks. The aim of such motivate and regulate health-related behaviours. education should be to enhance the cognitive and The most important cognitions appear to be per- social skills required to remain autonomous and sonal susceptibility to risk, perceived benefits of actively involved in decision making. Rehearsal, and barriers against an action, social approval, role play, script analysis and the participative perceived self-efficacy, and intention formation development of culturally appropriate positions and context-specific planning. However, whatever and procrastination strategies will all be necessary the attributes of the individuals involved, what to achieve this aim. happens in sexual encounters is largely the result

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of the interaction that takes place and the context context and safe sex; Australian adolescents' responses to AIDS. Journal of Applied Social Psychology, 22, 1374-1398. within which the encounter occurs. Sex education Boyd, B. and Wandersman, A. (1991) Predicting undergraduate programmes must take this into account in improv- condom use with the Fishbein and Ajzen and the Triandis ing understanding, targeting cognitions and attitude-behaviour models: implications for public health interventions. Journal of Applied Social Psychology, 21, developing social skills. 1810-1830. This overview is intended to provide a psycho- Boyer, C. B. and Kegeles, S. M. (1991) AIDS risk and social theoretical framework for initial thinking prevention among adolescents. Social Science and Medicine, 33, 11-23. about interventions; we have not attempted here Bury, J. (1984) Teenage Pregnancy in Britain. Birth Control to address the many subsequent steps that have to Trust, London. be taken to apply these insights in practice. These Catania, J. A., Kegeles, S. M. and Coates, T. J. (1990) Towards an understanding of risk behaviour an AIDS Risk Reduction include, amongst other things: identifying the most Model (ARRM). Health Education Quarterly, 17, 53-72. appropriate intervention and setting for one's target Christopher, F. S and Roosa, M. W. (1991) An evaluation of group; clarifying the constraints imposed by this an adolescent pregnancy prevention program: is 'Just say no' enough? Relations, 39, 68-72. particular intervention and those who are to deliver Conner, M. and Norman, P. (1996) Predicting Health Behaviour; it; formulating realistic learning outcomes; struc- Research and Practice with Social Cognition Models. Open turing these in a framework; and then engaging in University Press, Buckingham Cowie, C. and S. Lees. (1987) Slags and drags. In Sexuality: the cycle of writing, piloting, modifying and re- A Reader. London, Virago, pp. 105-123. piloting the programme. Dixon, H., Wight, D., Abraham, C. and Scott, S. (19%) SHARE: Sexual Health And Relationships—Safe, Happy and Responsible. Medical Research Council, Medical Sociology References Unit, Glasgow. Fisher, J. D. and Fisher W. A. (1992) Changing AIDS risk behaviour. Psychological Bulletin, 111, 455-474. Abraham, C. and Sheeran, P. (1994) Modelling and modifying Foucault, M. (1979) Discipline and Punish: The Birth of the young heterosexuals' HIV-preventive behaviour, a review Prison. Peregrine, Harmondsworth. of theories, findings and educational implications. Patient Foucault, M. (1981) The History of Sexuality: Volume 1. Education and Counselling, 23, 173-186. Penguin, Harmondsworth. Abraham, C, Sheeran, P., Spears, R. and Abrams, D. (1992) Gagnon, J. H. and W. Simon. (1974) Sexual Conduct: The Health beliefs and the of HIV-preventive intentions Social Sources of . Hutchinson, London. among teenagers; a Scottish perspective. Health Psychology, Giddens, A. (1990) The Consequences of Modernity. Polity, 11, 363-370. Cambridge. Abraham, C. Sheeran, P. Abrams, D. and Spears, R. (1996) Giddens, A. (1991) Modernity and Self Identity. Polity, Health beliefs and teenage condom use; a prospective study. Cambridge. Psychology and Health, 11, 641-655. Gold, D. and Berger, C. (1983) The influence of psychological Adams, J. (1995) Risk. UCL Press, London. and situational factors on the contraceptive behaviour of Bagozzi, R. P. (1992) The self-regulation of attitudes, intentions single men: a review of the literature. Population and and behaviour. Social Psychology Quarterly, 55, 178-204. Environment, 6, 113—129. Bandura, A. (1992a) Exercise of personal agency through the Gollwitzer, P. M. (1993) Goal achievement: the role of self-efficacy mechanism. In Schwarzer, R. (ed.), Self-efficacy: intentions. European Review of Social Psychology, 4, 142- Thought Control of Action. Hemisphere, Washington, pp. 185. 66-97. Hawkes, G. (1996) A Sociology of Society and Sexuality. Open Bandura, A. (1992b) Self-efficacy mechanism in psychobiologic University Press, Buckingham. functioning. In Schwarzer, R. (ed.), Self-efficacy: Thought Health Education Authority (1994) Health Update 4: HIV/AIDS Control of Action. Hemisphere, Washington, pp. 155-189. and Sexual Health. Health Education Authority, London. Beck, U. (1992) Risk Society. Sage, London. Hingson, R. W., Strunin, L., Berlin, M. and Heeren, T. (1990) Bellaby, P. (1990) To risk or not to risk? Uses and limitations Beliefs about AIDS, use of alcohol and drugs and unprotected of Mary Douglas on risk-acceptability for understanding sex among Massachusetts adolescents. American Journal of health and safety at work and road accidents. Sociological Public Health, 80, 295-299. Review, 38, 465-83. Holland, J., Ramazanoglu, C, Scott, S., Sharpe, S. and Berger, P. and T. Luckmann. (1966) 77K Social Construction Thomson, R. (1990) Sex, gender and power young women's of Reality. Anchor Books, New York. sexuality in the shadow of AIDS. Sociology of Health and Bloor, M., Barnard, M., Finlay, A. and McKeganey, N. (1993) Illness, 12, 336-50. HTV-related risk practices among Glasgow male prostitutes. Holland, J., Ramazanoglu, C, Scott, S., Sharpe, S. and Medical Anthropology Quarterly, 7, 1-19. Thomson, R. (1991) Between embarrassment and trust; Boldero, J., Moore, S. and Rosenthal, D. (1992) Intention, young women and the diversity of condom use. In Aggleton,

328 A psycho-social theoretical framework for sexual health promotion

P., Davies, P. and Hart, G. (eds), AIDS: Responses, Mellanby, A. R., Phelps, F. A., Crichton, N J. and Tripp, J. H. Intervention and Care. Falmer, Basingstoke, pp. 127-148. (1995) School sex education: an experimental programme Holland, J., Ramazanoglu, C, Sharpe, S. and Thomson, R. with educational and medical benefit. British Medical (1992) Pleasure, pressure and power some contradictions of Journal, 311, 414-417. gendered sexuality. Sociological Review, 40, 645-674. Miller, L. C, Bertencourt, B. A., DeBro, S. C. and Hoffman, Hollway, W. (1984) Gender difference and the production of V. (1993) Negotiating safer sex; interpersonal dynamics. In subjectivity. In Henriques, J., Hollway, W., Urwin, C, Pryor, J. B. and Reeder, G. D. (eds). The Social Psychology Venn, C. and Walkerdine, V. (eds), Changing the Subject: of HIV Infection. Lawrence Eribaum, Hillsdale, NJ, pp. Psychology, Social Regulation and Subjectivity. Methuen, 85-123. London, pp. 227-264. Morgan D. and Scott, S.(1993) Bodies in a social landscape. Ingham, R., Woodcock, A. and Stenner, K. (1991) Getting to In Scott, S. and Morgan, D. (eds), Body Matters: Essays on know you...young people's knowledge of their partners at the Sociology of the Body. Falmer, Brighton. first intercourse. Journal of Community and Applied Social Oakley, A., Fullerton, D., Holland, J., Arnold, S., France- Psychology, 1, 117-132. Dawson, M., Kelley, P. and McGrellis. S. (1995) Sexual health Jackson, S. (1982) Childhood and Sexuality. Blackwell, Oxford. education interventions for young people: a methodological Jackson, S. (1996) Social construction of female sexuality. In review. British Medical Journal, 310, 158-162. Jackson, S. and Scott, S. (eds), Feminism and Sexuality: A Polit-O'Hara, D. and Kahn, J. (1985) Communication and Reader. Edinburgh University Press, Edinburgh, pp. 62-73. contraceptive practices in adolescent couples, Adolescence, Jackson, S. and Scott, S. (eds) (1996) Feminism and Sexuality: 20, 33-42. A Reader. Edinburgh University Press, Edinburgh. Prendergast, S (1987) Girl's experience of menstruation in Jemmott, L. S. and Jemmott, J. B. (1991) Applying the theory school. In Holly, L. (ed.) Girls and Sexuality, Teaching and of reasoned action to AIDS-risk behaviour condom use Learning. Open University Press, Buckingham. among young black women. Nursing Research, 40, 228-234. Richard, R., van der Pligt, J. and De Vries, N. (1995) Anticipated Jemmott, J. B., Jemmott, L. S. and Fong, G. T. (1992) affective reactions and prevention of AIDS, British Journal Reductions in HTV risk-associated sexual behaviours among of Social Psychology, 34, 9-21. Black male adolescents: effects of an AIDS prevention Rotheram-Borus, M. J., Koopman, C, Haignere, C. and Davies, intervention. American Journal of Public Health, 82, 372-77. M. (1991) Reducing HIV sexual risk behaviours among Johnson, A.M., Wadsworth, J., Wellings. K. and Field, J. (1994) runaway adolescents. Journal of the American Medical Sexual Attitudes and Lifestyles. Blackwell Scientific, Oxford. Association, 266, 1237-1241. Kashima, Y., Gallois, C. and McCamish, M. (1993). The theory Royal College of Obstetricians and Gynaecologists (1991) of reasoned action and cooperative behaviour: it takes two Report of the RCOG working party on unplanned pregnancy. to use a condom. British Journal of Social Psychology, 32, RCOG, London. 227-239. Schaalma, H., Kok, G. and Peters, L. (1993) Determinants of Kelly, L (1988) Surviving Sexual Violence. Polity, Cambridge. consistent condom use by adolescents: the impact of Kent, V., Davies, M., DevereU, K. and Gottesman, S. (1990) experience of sexual intercourse. Health Education Research, Social interaction routines involved in heterosexual 8, 255-269. encounters: prelude to first intercourse. PapeT presented at Schaalma, H., Kok, G., Bosker, R., Parcel, G., Peters, L., Fourth Conference on Social Aspects of AIDS. South Bank Poelman, J. and Reinders, J. (1996) Planned development Polytechnic, London. and evaluation of AIDS/STD education for secondary-school Kirby, D., Short, L., Collins, J., Rugg, D., Kolbe, L., Howard, students in the Netherlands: short-term effects. Health M., Miller, B., Sonenstein, F. and Zabin, L. S. (1994) School- Education Quarterly, 23, 469-87. based programs to reduce sexual risk behaviours: a review Schinke, S. P. and Gordon, A. N. (1992) Innovative approaches of effectiveness. Public Health Reports, 109, 339-360. to interpersonal skills training for minority adolescents. In Kitzinger, J. (1995) 'I'm sexually attractive but I'm powerful': DiClemente, R. J. (ed.), Adolescents and AIDS; A Generation young women negotiating sexual reputation. Women's Studies in Jeopardy. Sage, Newbury Park, CA, pp. 181-193. International Forum, 18, 1-8. Schutz, A. (1970) Reflections on the Problem of Relevance. Kok, G. and Green, L. W. (1990) Research to support health Yale University Press, New Haven, CT. promotion in practice: a plea for increased co-operation. Scott, S. Jackson, S. and Milbum, K. (1997) Swings and Health Promotion International, S, 303-307. roundabouts: parental 'risk anxiety' and the everyday worlds Kok, G. (1993) Why are so many health promotion programs of children. Paper presented at The British Sociological ineffective? Health Promotion Journal of Australia, 3, 12-17. Association Annual Conference, York, April. Laws, S. (1990) Issues of Blood: The Politics of Menstruation, Scott, S. and Freeman, R. (1995) Prevention as a problem of Macmillan, London. modernity: the example of HTV and AIDS. In Gabe, J. Lawson, A. (1988) Adultery: An Analysis of Love and Betrayal. (ed.), Medicine, Health and Risk: Sociological Approaches. Oxford University Press, Oxford. Blackwell, Oxford, pp. 151-170. Lees, S. (1993) Sugar and Spice. Penguin, Harmondsworth. Scott, S. and Williams, G. (1992) Introduction. In Scott, S., Martin, B. (1981) A Sociology of Contemporary Cultural Williams, G.,, Plan, S. and Thomas, H. (eds), Public Risks Change. Basil Blackwell, Oxford. and Private Dangers. Avebury, Aldershot McRobbie, A, (1996) More! New sexualities in girls' and Sheeran, P. and Abraham, C. (1996) The health belief model. women's magazines. In Curran, J., Morley, D. and In Conner, M. and Norman, P. (eds), Predicting Health Walkerdine, V. (eds). Cultural Studies and Communication. Behaviour; Research and Practice with Social Cognition Edward Arnold, London, pp. 172-194. Models. Open University Press, Buckingham, pp. 23-61.

329 D. Wight et al.

Sherr, L. (1987) An evaluation of the UK government health disease prevention among adolescent users of oral education campaign on AIDS. Psychology and Health, 1, contraceptives. Family Planning Perspectives, 23, 71-74. 61-72. Wellings, K. (19%) Young Women's Magazines and Teenage SNAP Report, Scottish Needs Assessment Programme (1994) Sex: A Working Paper. Department of Public Health and Teenage Pregnancy in Scotland. Scottish Forum for Public Policy, London School of Hygiene and Tropical Medicine, Health Medicine, Glasgow University, Glasgow. London. Thomson, R. (1993) Unholy alliances: the recent politics of West, P., Wight. D. and Macintyre, S. (1993) Heterosexual sex education. In Bristow, J. and Wilson, A. (eds), Activating behaviour of eighteen year olds in the Glasgow area. Journal Theory. Lawrence and Wishart, London, pp. 219-244. of Adolescence, 16, 367-396. Thomson, R. and Scott, S. (1991) Learning about Sex: Young Wight, D. (1993a) A re-assessment of health education on HIV/ Women and the Social Construction of Sexual Identity. WRAP AIDS for young heterosexuals. Health Education Research, 8, 473-483. paper 4. Tufnell Press, London. Wight, D. (1993b) Constraint or cognition? Young men and Van der Velde, F. W. and van der Pligt, J (1991) AIDS-related safer heterosexual sex. In Aggleton, P., Davies, P. and Hart, health behaviour coping, protection motivation and previous G. (eds), AIDS: Facing the Second Decade. Falmer, London, behaviour. Journal of Behavioural Medicine, 14, 429-451. pp. 41-60. Walter, H. J. and Vaughan, M. S. (1993) AIDS risk reduction Wight, D. (1994) Boys' thoughts and talk about sex in a among a multiethnic sample of urban high school students. working class locality of Glasgow. Sociological Review, 42, Journal of the American Medical Association, 270, 725-730. 703-737. Weinstein, N. D. (1988) The precaution adoption process. Wight, D. (1997) Does sex education make a difference? Health Health Psychology, 7, 355-386. Education, 2, 52-56. Weisman, C. S., Plichta, S. Nathanson, C. A., Ensminger, M. and Robertson, J. C. (1991) Consistency of condom use for Received February 18, 1997; accepted June 21, 1997

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