BACK ON THE MARKET: UNDERSTANDING HETEROSEXUAL MATURE ADULT PROTECTIVE SEXUAL BEHAVIOURS
Natalie Erin Bowring
Master of Public Health (Health Promotion)
Bachelor of Mass Communication
Submitted in fulfilment of the requirements for the degree of Master of Business (Research)
School of Advertising, Marketing and Public Relations QUT Business School
Queensland University of Technology 2020 STATEMENT OF ORIGINAL AUTHORSHIP
The work contained in this thesis has not been previously submitted to meet requirements for an award at this or any other higher education institution. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made.
Signature: QUT Verified Signature
Date: 30/06/2020
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ABSTRACT
Sexual health continues to be a socially complex problem in Australia with sexually transmitted infections (STIs) such as chlamydia, gonorrhoea and syphilis rates continuing to rise despite extensive government and social marketing initiatives (Firestone, Rowe, Modi, & Sievers, 2017). The number of over-50s contracting chlamydia, gonorrhoea and syphilis has nearly doubled in Queensland over the past four years increasing form 541 reported STIs to 1,078 cases in 2017 (National Notifiable Diseases Surveillance System, 2020). Heterosexual Mature Adults (HMAs) aged 50 years and older have a distinctive life history which has resulted in a consumer market that is confident in who they are and what they want from sexual experiences but have little awareness of the changing health environment (DeLamater & Koepsel, 2015; Marshall, 2011a; Quine, Bernard, & Kendig, 2006). These adults are therefore re-entering the dating market with liberal sexual attitudes, limited risk perceptions and possibly no experience of condom use or negotiation (Gewirtz-Meydan et al., 2019). Current social marketing interventions ignore this growing group of consumers and instead focus on youth, homosexual, indigenous and ethnic minorities as they are incorrectly deemed more likely to engage in higher risk sexual behaviours (Dimbuene, Emina, & Sankoh, 2014).
Evidence demonstrates that condoms are not designed for use by mature consumers who have physiological barriers that decrease positive experiences of condom use (Messelis, Kazer, & Gelmetti, 2019b). Traditionally sexual health and social marketing condom interventions focus on individual insights and the social psychological barriers with little understanding of the mature customer experience. This dominant emphasis in practice and scholarship on individual behaviour reveals a significant gap in the social marketing literature pertaining to condom use. Specifically little is known about the lived customer experience of condom use by HMAs and the complexity of shared experiences (Johnston & Kong, 2011; Palmer, 2010). This research aimed to understand how psychosocial scripts influence condom use behavior and how lived experiences contribute to the success or failure of condom use behaviour.
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A qualitative research method was selected where social reality is constructed thorough subjective and consensual meanings (Denzin & Lincoln, 2011). This perspective focuses on understanding the construction of knowledge and local truths within a specific culture and or context (Yilmaz, 2013). A purposeful national sample of 24 adults aged 50 years and older who self-identified as heterosexual and were not in a committed relationship were invited to participate. There was an even distribution of males and females within the sample and their ages ranged between 50-70 years old. Due to the sensitive nature of the topic a semi-structured interview approach with the use of projective bubble drawings was used allowing exploration of intimate thoughts and feeling in a painless unobtrusive way (Donoghue, 2000). The process elicited rich data on the complexity of sexual experiences and how the customer experience of condom use connects to their anticipated experience and sexual outcome. Thematic analysis of verbal transcripts and visual data was conducted using NVivo and followed an inductive deductive approach (Fereday & Muir-Cochrane, 2006).
The analyses revealed that the purpose of having sex (connection, desire and gratification) was the key determinate of condom use by HMAs and that their lived experiences underpin the positioning and practice of condom use behaviour. The theoretical contributions of this research include: 1) the customer experience elements of condom use form the process and outcome of the behaviour, 2) the value spheres framework has been extended to include the shared sphere and 3) the Anti-Experience: products and services that inhibit or distort the experiential objective. This research provides valuable insights on HMA sexual behaviours and understanding of complex behavioural experiences that involve more than one person. It also provides potential strategies to enable social marketers and sexual health partitioners to develop effective and efficient interventions to increase condom usage by mature consumer markets.
Key words: Social marketing, customer experience, sexual health, heterosexual mature adults, shared sphere, anti-experience, value, condom use.
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ACKNOWLEDGEMENTS
I dedicate this thesis to my late grandfather Dr. Alywn Galwey a lifelong learner and supporter of higher education.
I would firstly like to sincerely thank my principle supervisor, Professor Rebekah Russell Bennett for going on this very long but rewarding journey. Your faith, guidance and encouragement has made this thesis possible. You have presented me with invaluable and unique opportunities, and I cannot thank you enough. Dr Sven Tuzovic thank you for coming on board as my associate supervisor and reading my drafts and providing supportive and timely feedback. I would also like to thank Adjunct Professor Judy Drennan who started on this journey with me and literally got to sail off into the sunset. Your enthusiasm, passion and support were instrumental in shaping this work.
To my friends Sandy Sergeant, Nicholas Grech, Jenna Campton, Libby Horwood and Christine Pike thank you for your support and suffering with me. Thank you for letting me use you as sounding boards, coffee dates and distractions. I would have truly lost my mind without you.
To my little study buddies Bella and Paddy your furry faces and companionship during the hours and hours stuck at the computer is greatly appreciated. Mable you were only a distraction.
Finally, I must express my very profound gratitude to my parents Nigel and Darolyn Harris and to my husband Paul and daughter Abigail for providing me with unfailing support and continuous encouragement throughout my years of study and through the process of researching and writing this thesis. This accomplishment would not have been possible without you. Thank you.
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Table of Contents
Statement of Original Authorship ...... i Abstract ...... ii Acknowledgements ...... iv List of Figures ...... vii List of Tables ...... ix Glossary of Terms ...... x Chapter 1: Introduction ...... 1 1.1 Sexual Health a Socially Complex Problem ...... 2 1.2 Context: Protective Sexual Behaviours and Heterosexual Mature Adults ...... 4 1.3 Sexual Health and Heterosexual Mature Adults ...... 6 1.4 Research Gaps and Research Questions ...... 7 1.5 Theoretical Frameworks ...... 8 1.6 Scope of Thesis ...... 10 1.7 Research Design ...... 11 1.8 Contribution to Theory and Practice ...... 11 1.9 Chapter Summary and Thesis Outline...... 13 Chapter 2: Literature Review ...... 14 2.1 Introduction ...... 14 2.2 Disciplinary Lens ...... 14 2.3 Social Marketing Lens ...... 16 2.4 Sexual Health Lens ...... 17 2.5 In Bed Together: Social Marketing and Sexual Health ...... 21 2.6 Social Marketing Campaigns for Sexual Health ...... 22 2.7 From Sexology to Sexual Health: An Experiential Perspective ...... 24 2.8 Protective Sexual Behaviours: Sheathing the Penis ...... 33 2.9 The Condom: Contraception or Prophylactic? ...... 39 2.10 Heterosexual Mature Adults Sex and Sexuality Literature ...... 40 2.11 Theoretical framework 1- Sexual Scripting ...... 43 2.12 Customer Experience Literature ...... 49 2.13 Theoretical Framework 2- Six Component Customer Experience Framework ...... 55 2.14 Chapter Summary ...... 58 Chapter 3: Research Design ...... 59 3.1 Philosophical Approach ...... 59 3.2 Qualitative Research Methods ...... 61 3.3 Interviews ...... 63
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3.4 Projective Techniques ...... 63 3.5 Sampling Strategy ...... 65 3.6 Interview Design ...... 66 3.7 Data analysis ...... 68 3.8 Ethical clearance ...... 70 3.9 Chapter Summary ...... 70 Chapter 4: Results ...... 71 4.1 Introduction ...... 71 4.2 Sample Characteristics ...... 71 4.3 Condom Attitudes and Use ...... 74 4.4 How do psychosocial scripts influence condom use behaviour by heterosexual mature adults? ...... 79 4.5 How do HMAs perceive the lived experience of condom use and how does this co- create value? ...... 99 4.6 Methodological Observations...... 115 4.7 Chapter Summary ...... 116 ...... 117 5.1 Introduction ...... 117 5.2 RQ1: How do psychosocial scripts influence condom use behaviour by heterosexual mature adults? ...... 117 5.3 How do HMAs perceive the lived experience of condom use and how does this co- create value? ...... 118 5.4 Theoretical Contributions ...... 119 5.5 Managerial Contributions ...... 124 5.6 Research Limitations and future research...... 127 5.7 Conclusion ...... 127 References ...... 128 Appendices ...... 145 Appendix A - Sexually Transmitted Infections ...... 145 Appendix B - Application of Context to SM Benchmark Criteria ...... 146 Appendix C - Application of Context to Ottawa Charter...... 147 Appendix D - Media Release ...... 148 Appendix E - Q&A Participant Screener ...... 149 Appendix F - Interview Guide ...... 151 Appendix G - Emotion Stickers ...... 154 Appendix H - Sample Code Book ...... 155
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LIST OF FIGURES
Figure 1. NNDS of STI Notifications by Australian Adults Aged 50+ for 2019……………… 3 Figure 2. Disciplinary Lens……………………………………………………………………. 16 Figure 3. Application of Social Marketing Offering to Protective Sexual……………………. 18 Figure 4. The Ottawa Charter………………………………………………………………….. 19 Figure 5. Sexual health: an operational approach……………………………………………… 21 Figure 6. Social Marketing and Sexual Health Commonalities and Differences……………… 22 Figure 7. Chronological Development of Sexuality Research………………………………… 25 Figure 8. Product Development of the Condom……………………………………………….. 34 Figure 9. Sexual Scripting of HMA Sexual Behaviour……………………………………….. 46 Figure 10. Customer Experience Framework…………………………………………………. 56 Figure 11. Bubble Drawing without a Condom……………………………………………….. 67 Figure 12. Bubble Drawing with a Condom…………………………………………………… 67 Figure 13. Data Analysis Process……………………………………………………………… 69 Figure 14. Male Sample Characteristics……………………………………………………..… 72 Figure 15. Female Sample Characteristics…………………………………………………….. 73 Figure 16. Attitudes towards condoms………………………………………………………… 75 Figure 17. Heterosexual Mature Adult Sexual Scripts………………………………………… 79 Figure 18. World War II………………………………………………………………………. 84 Figure 19. Grim Reaper……………………………………………………………………...... 84 Figure 20. Positioning of Prophylactic Protective Sexual Behaviour……………………….… 86 Figure 21. Practice of Prophylactic Protective Sexual Behaviour…………………………...… 89 Figure 22. Purpose of Sexual Experience ……………………………………………………. 94 Figure 23. Conceptualization of HMA Prophylactic Protective Sexual Behaviour…………… 95 Figure 24. Sexual Script Alignment and HMA Prophylactic Sexual Behaviour………...……. 96 Figure 25. The Customer Experience of Mature Sex………………………………………….. 99 Figure 26. Male Participant’s Experience of Sex…………………………………………….. 100 Figure 27. Female Participant’s Experience of Sex………………………………………….. 100 Figure 28. Emotional Element- Embarrassment……………………………………………… 102 Figure 29. Pragmatic Element- Female Not Making a Fuss………………………………….. 103 Figure 30. Cognitive Element- Excerpt from Figure 26………………………………………. 104 Figure 31. Cognitive Element- Excerpt from Figure 27……………………………………… 104 Figure 32. The Mature Customer Experience of Condom Use………………………………. 105 Figure 33. Male Participant’s Customer Experience of Condom Use……………………….. 106 Figure 34. Female Participant’s Customer Experience of Condom Use……………………… 106 Figure 35. Experiential Mechanisms of Prophylactic Condom Use………………………….. 109 Figure 36. Process of Condom use………………………...…………………………………... 111 Figure 37. Outcome of Condom use …………………………...……………………………… 111 Figure 38. Evidence of the Shared Experience of Condom Use……………………………… 112 Figure 39. Evidence of the Shared Experience of Condom Use…………………………...….. 113 Figure 40. The Shared Experience of Condom Use ……………………………………...…… 113 Figure 41. The Anti-Experience of Condom Use……………………………………………… 114 Figure 42. Customer Experience of Protective Sexual behaviour: Process vs Outcome……… 120
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Figure 43. The Shared Sphere……………………………………………...………………….. 121 Figure 44. The Customer Experience Process………………………………..……………...… 123 Figure 45. The Anti Experience………………………………………………………………... 123
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LIST OF TABLES
Table 1 Research Contributions………………………………………………………………….. 13 Table 2. Application of Operational Approach to HMA Sexual Health…………………………. 22 Table 3. Table 4. Applications of Sexual Scripting Theory……………………………………………….. 45 Table 5. Roots of Customer Experience Literature 1982-1998………………………………… 50 Table 6. Customer Experience and the Role of the Firm Literature……………………………… 52 Table 7. Customer Experience and Responses to Consumption Literature……………………… 53 Table 8. Research Paradigms…………………………………………………………………….. 60 Table 9. Qualitative Data Collection Methods and Suitability to this Research…………………. 62 Table 10. Projective Techniques Classifications and Activities………………………………… 64 Table 11 Contraceptive Choices………………………………………………………………….. 77 Table 12. Positioning of Prophylactic Protective Sexual Behaviour…………………………… 80 Table 13. Practice of Prophylactic Protective Sexual Behaviour ………………………………... 86 Table 14. Purpose of Sexual Experience and Prophylactic Condom…………………………….. 90 Table 15. Customer Experience Motivators and Barriers of Prophylactic Condom Use………… 110 Table 16. Anti-Experiences Strategies for HMA Prophylactic Condom Use……………………. 125
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GLOSSARY OF TERMS
Australian Institute of Health and Morbidity: The ill health of an individual Welfare (AIWH): an independent and levels of ill health in a population or statutory agency providing authoritative group. and accessible information and statistics Mortality: Number or rate of deaths in a to support better decisions about policy population during a given time period. and service delivery, leading to better Public health: Activities aimed at health and wellbeing for all Australians. benefiting a population, with an emphasis Australian Bureau of Statistics (ABS): on prevention, protection and health is the independent statistical agency of promotion as distinct from treatment the Government of Australia. The ABS tailored to individuals with symptoms. provide key statistics on a wide range of Prophylactic: intended to prevent economic, population, environmental and disease. social issues, to assist and encourage Quality of life: the general well-being of informed decision making, research and individuals and societies, outlining discussion within governments and the negative and positive features of life. It community. observes life satisfaction, including Contraception: birth of fertility control, everything from physical health, family, is a method or device used to prevent education, employment, wealth, safety, pregnancy. security to freedom, religious beliefs, and Condom: a sheath-shaped barrier device the environment. used during sexual intercourse to reduce Sexual Scripting: the sociological, the probability of pregnancy or a sexually cultural, anthropological, historical and transmitted infection. social psychological study of human Customer Experience: a customers' sexualities holistic perception of their experience Sexually Transmissible Infection with processes or resources. (STIs): An infectious disease that can be Epidemic: a widespread occurrence of an passed from one person to another by infectious disease in a community at a sexual contact. particular time. Social determinants of health: The Endemic: a disease or condition regularly circumstances in which people are born, found among particular people or in a grow up, live, work and age, and the certain area. systems put in place to deal with illness. Burden of disease: a measure of Social marketing: integration of population health that aims to quantify the marketing concepts with other approaches gap between the ideal of living to old age to influence behaviours that benefit in good health, and the current situation individuals and communities for the where healthy life is shortened by illness, greater social good. injury, disability and premature death. World Health Organisation (WHO): a Health promotion: A broad term to specialised agency of the United Nations describe activities that help communities that is concerned with world public and individuals increase control over their health. health behaviours. Health promotion focuses on addressing and preventing the root causes of ill health, rather than on treatment and cure. Heterosexual: Heterosexuality is romantic attraction, sexual attraction or sexual behaviour between persons of the opposite sex or gender.
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Chapter 1: Introduction
Social Marketing is defined as the use of commercial marketing concepts and techniques to induce behavioural change that benefits individuals and communities for the greater social good (Dann, 2010a; Lee & Kotler, 2011; Rothschild, 1999a). The discipline’s ‘marketing’ lens has become an integral part of public health and sexual health promotion interventions to change behaviour and address social challenges (French, Blair-Stevens, McVey, & Merritt, 2010). Social marketing has effectively been used to address socially complex problems such as alcohol, domestic violence, obesity, climate control, smoking, road safety, substance abuse and sexual health (Andreasen, 2002; Gordon, Russell-Bennett, & Lefebvre, 2016; Kotler & Roberto, 1989). This success has been attributed to social marketing’s critical and systematic approach to behaviour change based on the core principle of social value creation through marketplace exchange (French & Russell-Bennett, 2015).
In the 21st century, there is still an unacceptably high global incidence of sexually transmitted infections (STIs). More than a million bacterial, viral or protozoa STIs are acquired every day causing significant burden of disease (WHO, 2018) . The World Health Organisation’s (WHO) has developed a global strategy to address STI morbidity and mortality which includes strengthening data monitoring, STI prevention, early diagnosis, patient and partner management and initiating approaches to reach the most vulnerable populations (WHO, 2017b). An emerging vulnerable population and increasing social marketing and public health concern is heterosexual mature adults (HMAs) aged 50 years and older (DeLamater & Koepsel, 2015; Marshall, 2011; Smith, Mulhall, Deveci, Monaghan, & Reid, 2007; Smith, 2011; Somes & Donatelli, 2012; Taylor & Gosney, 2011). Also known as “Baby Boomers” this population were born between 1946 and 1966 during the post-war economic boom (Australian Bureau of Statistics, 2008). Biologically pregnancy is no longer an issue for this age group and protective sexual products such as condoms are perceived as contraceptive rather than prophylactic as a result of historical events and societal norms (DeLamater, 2012; DeLamater & Moorman, 2007; Family Planning
Introduction 1
Association, 2010). Increasing rates of divorce, separation and death combined with online platforms, affordable travel, and advancements in menopausal and sexual dysfunction treatments, has also enabled HMAs to meet and engage in risky casual sexual encounters more easily. Sexual encounters should not be discouraged in HMAs as sexual activity is linked to both positive health outcomes and quality of life (Carpenter, Nathanson, & Kim, 2006; Marshall, 2011). Reports have found that engaging in penile-vaginal intercourse is correlated to higher quality of intimate relationships, lower rates of depressive symptoms and improved cardiovascular health (Brody, 2010). This thesis aims to understand the customer experience of heterosexual mature adult sexual activity and how they navigate protective sexual behaviours. This chapter introduces the thesis, the context of the research, and overviews the managerial and theoretical problems to be addressed. This is followed by the scope, research methods and the theoretical and managerial contributions made. The chapter will conclude with a summary of the chapter and provide a thesis outline for the remaining chapters.
1.1 Sexual Health a Socially Complex Problem
Sexual health continues to be a socially complex problem in Australia and a topic for social marketers with sexually transmitted diseases (STIs) such as chlamydia, gonorrhoea and syphilis rates continuing to rise despite extensive government and public health initiatives. Chlamydia notification rates have substantially increased since 1999 with a peak rate of 385 infections per 100,000 people in 2016 (AIHW, 2018). Similarly, gonorrhoea notification rates have more than tripled from 36 to 118 notifications per 100,000 people and syphilis has more than doubled from 10 to 26 notifications per 100,000 people (Australian Institute of Health and Welfare, 2018). Increases have been associated with the gradual introduction of more sensitive laboratory tests and the increase of tests being performed. Data collected by the National Notifiable Disease Surveillance System (2019) saw a significant spike in Chlamydia and Gonorrhoea amongst mature adults (Figure 1). Please note that HIV has been excluded from this figure as HIV notification and tracking are handled by The Kirby Institute for infection and immunity in society. The latest data from the HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report (2018) has identified that heterosexual sex accounts for 25% of
2 Introduction
new notifications of HIV and that notifications in those 50 years or older has increased by 5% (Kirby Institute, 2018).
Figure 1. STI Notifications by Australian Adults Aged 50+ for 2019
Reported number of Mature Adult STIs by Pathogen and Age 2000
1800
1600
1400
1200
1000
800
600 Number of NumberNotificationsof 400
200
0 Chlamydia Gonorrhoea Syphilis Hepatitis B Hepatitis C
50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Sourced from the National Notifiable Disease Surveillance System (2019)
While there is surveillance of STIs in mature adults scholars and practitioners agree that the number of cases identified are only a small proportion of the actual prevalence within the population making STIs a hidden epidemic of tremendous health and economic consequences (Braxton et al., 2018). Heterosexual Mature Adults (HMAs) in particular are not representative within these statistics as a result of ageist attitudes towards aging populations and stigmatism around sex and sexuality (ABS, 2008; Marshall, 2011). Protective behavioural interventions and education of condom use is not targeted at HMAs but rather focus on youth and homosexual markets despite their effectiveness in reducing the transmission of STIs.
1.1.1 The Condom: Contraceptive or Prophylactic The male condom is still the most efficient way to reduce the sexual transmission of HIV and other STIs. Social marketing has been identified as a key component in the global strategy to increase condom use (Kennedy, Mizuno, Seals, Myllyluoma, &
Introduction 3
Weeks-Norton, 2000; Meekers, Agha, & Klein, 2005; Price, 2001; Sweat, Denison, Kennedy, Tedrow, & O'Reilly, 2012; Sweat et al., 2020). Adolescent and young adults, gay, bisexual, and other men who have sex with men and indigenous, racial, and ethnic minorities consumer markets are the primary target for social marketing behavioral change campaigns focused at increasing condom use. Despite the incident of STIs in those aged 50 years and older increasing, heterosexual mature consumer markets have been ignored. It is even suggested that STI rates within this market may even surpass that of younger demographics (Sweat et al., 2012).
One explanation for this increase is the contextualisation of heterosexual condom use as a contraceptive. The purpose of condom use has been positioned as either a contraceptive against pregnancy or prophylactic against disease dependent upon historical context, social norms and the target market of the time. HMAs were born during the sexual revolution where advancements in contraceptive technologies liberated sexual behaviours. Risk and fear of contracting an STI was not prominent as the AIDS epidemic had not occurred and common STIs (gonorrhoea, chlamydia and syphilis) were easily treatable. Thus HMAs are now finding themselves single due to death, separation or divorce of a spouse and may still retain beliefs that sexually transmitted infections (STIs), HIV and AIDs are only relevant to homosexual or younger consumer markets (Carr, 2004; DeLamater, 2012). This distinctive life history has resulted in a demographic that is confident in who they are and what they expect regarding sex and sexuality within traditional relationships and with little awareness of the changing health environment (Quine et al., 2006). They are therefore re-entering the dating market with liberal sexual attitudes, limited risk perceptions and possibly no experience of condom use or negotiation, thus resulting in risky casual sexual encounters (Gewirtz-Meydan et al., 2019). Understanding these life experiences and the role and context that condoms have played in developing older adult’s psychosocial scripts is vital for explaining HMA prophylactic protective sexual behaviours and the development of social marketing and public health interventions to increase condom use.
1.2 Context: Protective Sexual Behaviours and Heterosexual Mature Adults
Protective sexual behaviours are defined as the practice of responsible and accountable behaviours including condom use, reduction of sexual partners, sexual faithfulness and abstinence (Satcher, 2001; Snelling et al., 2007; Sullivan et al., 2017).
4 Introduction
The aim of these behaviours is to reduce or prevent an individual’s risk of unwanted pregnancy and/or contraction of a communicable sexually transmitted diseases (Appendix A) through the exchange of fluids such as salvia, semen, vaginal fluids or blood. This transmission can occur through oral sex using the mouth, lips or tongue to stimulate partner’s genitals or anus and penetrative vaginal or anal sex with genitals and/or vibrator/penetrative sex toy (WHO, 2006). Interventions promoting condom use as a protective sexual behaviour to prevent STIs and pregnancy traditionally focus on youth, homosexual, indigenous and ethnic minorities as they are more likely to engage in higher risk sexual behaviours such as sexual activities that involve passage of bodily fluids, sexual intercourse without the use of a condom, and/or multiple sexual partners e.g. serial sexual monogamy or concurrent sexual partnerships (Dimbuene et al., 2014). The dominant emphasis on contraception and youth consumer markets in practice and academia reveals a gap in both the sexual health and social marketing literature surrounding the customer experience of condom use by HMA and their lived experiences of prophylactic protective sexual behaviours specifically condom use.
1.2.1 Burden of Disease The true burden of STIs in heterosexual mature adults (HMAs) has been underestimated due to the many systemic barriers to preventive health care, underreporting, delayed diagnosis by physicians and/or the misdiagnosis of STI symptoms as “typical signs of aging” (Brooks, Buchacz, Gebo, & Mermin, 2012; Levy, 2002; Ogden, Richards, & Shenson, 2012; Zingmond et al., 2001). What we do know is that STI rates are increasing as indicated by national notification rates of sexually transmissible infections and blood- borne viruses 1996-2017 (Figure 1). Reported rates of STIs are only a small percentage of the actual rate of infection within the community and it can also be assumed that there is a disproportionate under representation of mature adults within this data. Health care professionals are reluctant to recognise or investigate the sexuality of their older patients and as a result STI symptoms are often misdiagnosed or mistaken for signs of ageing (Somes & Donatelli, 2012; Wilson, 2006). Consequently, older adults do not feel comfortable discussing symptoms with health professionals until they are debilitating or even life threatening (DeLamater, 2012; Marshall, 2011). Until diagnosis these older adults are unaware of their infection status and are still on the dating market engaging in risky sexual behaviours. HMAs have also traditionally been excluded from condom use campaigns
Introduction 5
despite the fact that untreated STIs increase the risk of social stigmatisation, pain, avoidable morbidity and contraction of other STIs such as HIV (Bodley-Tickell et al., 2008; Smith & Christakis, 2009). This makes them a crucial target market for social marketing and sexual health initiatives and research. Little is known about protective sexual behaviours such as condom use in mature consumer markets and the interplay of experience, gender role and sexual history.
1.3 Sexual Health and Heterosexual Mature Adults
HMA sexual health is a new frontier as the predominant focus of sex and health research, policy and service planning has been on adolescent and younger adult demographics (Kirkman, Kenny, & Fox, 2013). This omission has been attributed to the general perception and prejudices of an ‘asexual’ old age and the notion of sex by older people as disgusting and/or amusing (Taylor & Gosney, 2011). These beliefs are stereotypes and myths such as;
• Mature adults do not have sexual desires • Mature adults are unable to have sex even if they want to • Mature adults are too fragile and might hurt themselves if they engage in sexual activity • Mature adults are sexually unattractive and thus undesirable • Mature adult sex is shameful and perverse
(Drench & Losee, 1996; Henry & McNab, 2003; Marshall, 2011; Trudel, Turgeon, & Piché, 2010) Policy and health research has started to shift from a biomedical model of sexual functioning to a model of positive sexual health (DeLamater, 2012; Fooken, 1994; Marshall, 2011). For the first time researchers have acknowledged that not only do HMAs remain sexually active well into their 80’s, but these intimate encounters are associated with quality of life and positive health outcomes (DeLamater, 2012; Lindau et al., 2007; Marshall, 2011). Despite the emergence of this shift, it is still early days and there has been limited research into actual sexual behaviours of HMAs such as condom use especially as pregnancy may no longer be a risk. When determinants of HMA condom use are investigated, typically the research is within the context of homosexuality and or mature adults already living with HIV/AIDs (Brooks, Buchacz,
6 Introduction
Gebo & Mermin, 2012; Levy, 2002; Neundorfer, Braudy, Britton & Lynch, 2005; Smith, 2011).
1.4 Research Gaps and Research Questions
The following research gaps and questions have resulted from the examination of existing literature on sexual health, social marketing, mature adult sex and sexuality and prophylactic protective sexual behaviour of condom use. The gaps align with the managerial problem of increasing STIs and mature heterosexual adults’ protective sexual health behaviours.
Research Gap 1: There is a lack of understanding of the lived sexual experiences of HMAs and how historical narratives contribute to protective sexual behaviours (Marshall, 2011). Past research on mature adults has primarily focused on the determinates of sexual health, importance and quality of life as a result of sex and sexuality in later life and sexual health communication (Beutel, Stöbel‐Richter, & Brähler, 2008; Bretschneider & McCoy, 1988; DeLamater & Koepsel, 2015; Marshall, 2011). Thus, there is limited empirical research on the behavioural interactions of HMA within sexual encounters. This research thus aims to provide new understandings about the role psychosocial scripts plays and how these influences protective sexual behaviours and prophylactic condom use by mature heterosexual adults.
Gap 1. We do not know the lived sexual experiences of heterosexual mature adults and how they navigate protective sexual behaviours.
RQ1. How do psychosocial scripts influence the protective sexual behaviours of heterosexual mature adults?
Research Gap 2: There is a lack of understanding of the customer experience (CX) of protective sexual behaviours. Sexual health services and products facilitate the practice of protective sexual behaviour however, this has only been explored in the context of public health and primarily looks at the determinants of condom use in youth and homosexual consumer markets (Albarracín, Johnson, Fishbein, & Muellerleile, 2001; Braun, 2013; Broaddus, Morris, & Bryan, 2010; Davis et al., 2014; John, 2003). The customer experience literature within marketing is still in its nascent stage with
Introduction 7
little know about the phenomenon (Becker & Jaakkola, 2020; McColl-Kennedy et al., 2015). The literature has focused on conceptualisation of customer experience construct, creating good customers experiences across variety of offerings, user interaction and co-experiences between groups (Battarbee & Koskinen, 2005; Berry, Carbone, & Haeckel, 2002; Frow & Payne, 2007; McColl-Kennedy et al., 2015; Schmitt, 1999). There is limited understanding of CX outside of the product and service context. This research thus aims to provide new understandings about the elements of customer experience within an experiential behaviour and how the customer experience elements can motivate or inhibit the use of protective sexual products by HMAs.
Gap 2. We do not understand the customer experience of protective sexual behaviours for heterosexual mature adults.
RQ2. How does the customer experience of protective sexual products facilitate or inhibit heterosexual mature adult protective sexual behaviours?
1.5 Theoretical Frameworks
This research is embedded across the disciplines of Social Marketing and Sexual Health. Each of these fields are complementary to each other and offer critical insights to HMA sexual behaviours. How these lenses shape this research will be discussed in detail in Chapter 2. From the Social Marketing and Sexual Health disciplines two theoretical frameworks have been selected. Research Question 1 (RQ1) will use Simon and Gagnon’s (1984) Sexual Scripting Theory and Research Question 2 (RQ2) will use Gentile, Spiller, and Noci (2007) six component Customer Experience framework.
1.5.1 Sexual Scripting Theory Sexual Scripting Theory (SXS) proposes that people follow internalized scripts (cultural scenarios, interpersonal and intrapsychic) to construct meaning out of behaviour, emotion and interactions within a social context (Carpenter, 2010; Simon & Gagnon, 1984; Simon & Gagnon, 1986). The theory has been used extensively to explore and understand gender-roles and fluidity, discourses of sexual pleasure and relationships in youth consumer markets (Hoppe, 2011; Keys, 2002; Thorpe et al., 2019). SXS has only recently been applied to mature consumer markets but has only had a biomedical focus on functioning and desire (Alarcão, Machado, & Giami, 2016;
8 Introduction
Rutagumirwa & Bailey, 2018). This research uses SXS to understand HMA protective sexual behaviours and the contexts in which they occur.
SXS provides an intrapsychic map of how people feel, think and behave in certain situations (Simon and Gagnon, 1986). Thus, it is appropriate in understanding HMA prophylactic protective sexual behaviour as it incorporates their distinctive life history contextualising condom use (contraceptive and prophylactic), normative sexual behaviour, past sexual experiences, partner type and drivers such as desire, arousal, fantasies and intimacy. Given HMA’s life history is longer than a younger adult, it is likely that habits and strong beliefs which have been formed in a different era has resulted in distinctive motivations and barriers to protective sexual behaviours when compared to younger consumers. Sexual activity for HMAs fulfils the need for human connection, intimacy, desire, and emotional well-being (Byers, 1983, DeLamater, 2012, Marshall, 2011). Using a condom can be perceived as unnatural by mature adults and thus can be a barrier to this intimacy which effectively removes the purpose of the sexual activity (Braun, 2013). SXS helps understand the lived experience of HMAs and how they navigate protective sexual behaviours.
1.5.2 Customer Experience The six component customer experience framework (CXF) (Gentile, Spiller and Noci, 2007) explores the sensorial, emotional, relational, cognitive, pragmatic and lifestyle elements of the customer experience. This framework views the customer experience holistically and thus can be applied beyond a retail or services setting. This makes it suitable for exploring the customer experience elements of protective sexual products and how they potentially facilitate or inhibit heterosexual mature adult protective sexual behaviours. Despite the practical and theoretical evidence for sexual behaviour into old age there has been little, if any, research exploring protective sexual behaviours within this consumes market. (DeLamater, 2012; DeLamater & Koepsel, 2015; Fooken, 1994; Marshall, 2011). The high involvement of emotional, physical and social behaviours that form the complexity of sexual experiences provides a rich context in which to explore the psychosocial scripting and customer experience of protective sexual behaviours. Examining the CX of condoms will provide a new context for further understanding the nature of customer experiences.
Introduction 9
1.6 Scope of Thesis
The context of this thesis is protective sexual behaviours by heterosexual mature adults 50 years and older born between 1946 and 1964 inclusively. Heterosexual consumers are the focus of this research due to the duality in product nature: prophylactic and contraceptive. To heterosexual consumer markets, condoms are a protective product that are perceived as both protection from STIs (prophylactic) and pregnancy (contraceptive). This differs from homosexual (men who have sex with men) consumer markets where condoms are prophylactic only (McKusick, Horstman, & Coates, 1985). The use of condoms as a prophylactic has been extensively and consistently marketed to high risk homosexual target markets as a result of the AIDs/HIV epidemic in the 1980’s (Hunt et al., 1993; Valdiserri et al., 1988). This forms one of the issues with HMA consumer markets as they may have not been directly targeted with prophylactic protective messaging around condom use leading to misconceptions of STIs transmission and risk.
The market segment mature adults aged 50 years or older was selected due to physiological changes, societal norms around aging and previous studies in gerontology and public health literature. HMAs as defined by this research are largely past the reproductive stage in their life due to menopausal and hormonal changes. Thus the use of condoms for contraceptive reasons are no longer relevant (Ossewaarde et al., 2005). Some researchers believe that these changes also contribute to the notions of an “asexual” old age and the societal norms of mature sexuality (Taylor & Gosney, 2011). Sexual activity in mature adults is perceived as gross with the notion that you should not be having sex if you cannot have children. Finally when looking at the HIV literature and national surveillance of STIs in mature or older adults as they are referred to in public health are classified as 50 years and older (Levy, 2001; Schick et al., 2010; Smith, 2011).
Finally, HMAs who were not in a committed relationship were selected to participate as condom use is dependent upon the type of sexual relationship. Casual sexual encounters, hook-ups, one-night stands, friends with benefits and booty calls are all used to describe intimacy and or sexual activity outside of a committed romantic relationship and report higher rates of prophylactic condom use (Claxton & van Dulmen, 2013; Heldman & Wade, 2010). Research has also found that condom use is consistency higher with new or casual partners (Macaluso, Demand, Artz, & Hook,
10 Introduction
2000). Sexual relationships can change over time, for example becoming mutually exclusive or increased levels of trust can result in inconsistent or abandonment of condom use behaviour. Thus, an inclusion criterion that contextualised this research is that participants self-identified as single or not in a committed relationship.
1.7 Research Design
To understand the protective sexual behaviours of heterosexual mature adults 50 years and older a qualitative research method was selected. The epistemology of this study reflects a social constructivist perspective whereby social reality is constructed thorough subjective and consensual meanings (Denzin & Lincoln, 2011). This perspective focuses on understanding the construction of knowledge and local truths within a specific culture and or context (Derry, 1999; McMahon, 1997). A purposeful sample of 24 mature adults aged 50 years and older who self-identified as heterosexual and not in a committed relationship were invited to participate. There was an even distribution of males and females with the final samples ages ranging between 50-70 years old. Semi structured interviews and projective techniques were used to elicit the data from a sample of (Marshall & Rossman, 2015). Due to the sensitive nature of the topic a semi structured approach with the use of projective bubble drawing allowed exploration of sensitive thoughts and feeling in a painless unobtrusive way (Donoghue, 2000). Thematic analysis of verbal transcripts and visual data was conducted using NVivo and followed an inductive deductive approach (Fereday & Muir-Cochrane, 2006).
1.8 Contribution to Theory and Practice
This research provides three theoretical contributions: misalignment of the customer experience process and outcome, the shared value sphere and the anti- experience. This knowledge contributes to both the understanding of HMA sexual behaviours and the customer experience of protective sexual products. Theoretical and managerial applications of this research have implications for social marketers, sexual health practitioners, general practitioners, nurses, gerontologists and commercial producers of protective sexual products. The fist theoretical contribution established that misalignment of the customer experience process and outcome decreases protective sexual behaviours. This contribution allows for deeper understanding of how the elements of customer experience explain behaviour. The second contribution
Introduction 11
extends Grönroos and Voima’s (2013) value spheres by adding the shared sphere and other consumer. Active involvement in the shared experience was found to facilitate protective sexual behaviours. This contribution sheds light on shared experiences where a single service and or product is simultaneously used by two customers. The final contribution of this research extends the conceptualisation of the customer experience and proposes the Anti-Experience, whereby products and services inhibit or distort the experiential objective. This contribution moves away from the polarisation of good or bad experiences and acknowledges that elements of the customer experiences can be distorted and or inhibited by the consumption of the product or service creating said experience.
The research contributions provide three managerial implications and opportunities for social marketing, health practitioners and providers of protective sexual products; redesign of product elements to realign processes with the purpose, creation of value propositions for the shared experience and identification of potential anti-experiences and strategies. The contextual implications of these findings can be applied beyond the scope of HMA protective sexual behaviours. Insights can be applied to other consumer markets and protective behaviours that involve the use of products and services. There are also potential applications to commercial products and services that are simultaneously consumed by two or more people or could potentially create Anti-Experiences. Table 1 illustrates the alignment between the managerial problem, theoretical gaps, research questions and contributions.
Table 1. Research Contributions
Managerial Theoretical gap Research Theoretical Managerial Problem Questions contribution contributions MP1. Gap 1. RQ 1. Use of condoms by We do not know the How do 1) The customer 1) Redesign product mature adults is beliefs and attitudes psychosocial scripts experience elements of elements with mature inadequate. related to condom use influence condom condom use form the consumers to align with by heterosexual use behaviour by process and outcome of physical and mature adults and heterosexual mature the behaviour. psychological limitations how they navigate adults? protective sexual 2) Promote condoms behaviours. 2) The value spheres based on shared not MP2. Gap 2. RQ 2. framework has been individual value Condoms are not We do not know the How do HMAs extended to include the propositions. designed with the lived customer perceive the lived shared sphere. physical, experience elements experience of 3) Social Marketers need emotional and of condom use by condom use and 3) The Anti-Experience: to identify potential anti- cognitive needs of heterosexual mature how does this co- products and services that experiences and develop mature consumers consumers. create value? inhibit or distort the strategies within their experiential objective interventions
12 Introduction
1.9 Chapter Summary and Thesis Outline
Chapter 1 established that there is limited understanding of heterosexual mature adult protective sexual behaviours. Increasing rates of sexually transmitted infections in our largest population segment is unsustainable and evidence based protective sexual behaviour interventions are needed (DeLamater & Koepsel, 2015; Roberson, 2018). Further understanding of the lived sexual experiences of HMAs and practice of protective sexual behaviours will aid both social marketing and health practitioners create effective and efficient interventions for heterosexual mature consumers.
This thesis is comprised of five chapters. Following this introductory chapter; Chapter 2 provides a detailed discussion of current literature on customer experience, sex and sexuality and protective sexual behaviours. Through the syntheses and discussion of this literature two key research gaps and associated research questions will be presented along with the theoretical framework. Chapter 3 outlines the philosophical approach of this research and justifies the qualitative methods selected. The sampling procedures, methods, analysis of data, ethics and limitations are also discussed. Chapter 4 provides results of the research including the data analysis. Chapter 5 discusses the key findings and their theoretical and managerial contributions along with the implications, limitations and directions for future studies.
Introduction 13
Chapter 2: Literature Review
2.1 Introduction
Chapter 2 presents a detailed examination of the literature surrounding the core concepts of this thesis. Literature from the public health, social marketing, customer experience, sexuality, psychology, gerontology, anthropology and medical fields has been overviewed. The literature review begins by discussing the disciplinary lenses that shape this research: social marketing and sexual health. The thematic and chronological development of sex and sexuality research is then discussed as the modern approach to studying sex acknowledges the evolution of the field. Paradoxes and ideologies from the past are still evident within the discipline and are critical to understanding the theoretical and social aspects of sex and sexuality. Product development of the male condom is then discussed and interlinked with the prior discussion of sex and sexuality research to provide context of protective sexual behaviours and demonstrate the duality in product nature: contraceptive and prophylactic. Once the historical foundations and context of the research has been discussed the first core concept, HMA sex and sexuality is discussed. This will be followed by the second core concept, the customer experience of protective sexual behaviours. To answer the research questions presented in Chapter 1, two theoretical frameworks will be outlined: Simon and Gagnon (1984) Sexual Scripting and Gentile, Spiller, and Noci (2007) Six Component Customer Experience Framework. These frameworks will be discussed and applied to the research context of heterosexual mature adult protective sexual behaviours.
2.2 Disciplinary Lens
This research is embedded across the disciplines of Social Marketing and Sexual Health which is a subset of Public Health. These fields are complementary to each other and offer critical insights to understanding behaviour (Grier & Bryant, 2005). The primary aim of social marketing and sexual health is to facilitate behavioural change in order to increase benefits (health, environment, wellbeing, financial security, equity, education, opportunities) for individuals and society. They both are underpinned by theory, are driven from the inside out, are context specific
14 Literature Review
and rely on multiple strategies to enable change (Griffiths, Blair-Stevens, & Parish, 2009). Despite these commonalities, it should be noted that some public health practitioners perceive social marketing as a tool to be used as part of health promotion interventions rather than a disciplinary ally in the field of social change (Ling, Franklin, Lindsteadt, & Gearon, 1992). The key criticism made by public health practitioners is social marketer’s use of segmentation which echoes the discourse of social stratification and inequalities of health (Thurston, 2014). This forms the key difference between to two disciplines whereby public health focuses holistically on determinates of health within an entire populations and social marketers segment consumer markets and target specific behaviours for increased effectiveness and efficiency. Modern practitioners understand the value in working across disciplines drawing on the strengths of each. This research is positioned across social marketing and sexual health as seen in Figure 2. The left circle of the figure outlines key elements of social marking (French & Blair-Stevens) and the right circle outlines the foundation of the operational framework for sexual health (French & Blair-Stevens, 2006; WHO, 2017a). The following sections discuss each discipline and how each contextualises HMA protective sexual behaviours. The section then concludes by discussing how the two disciplines will be brought together to inform, shape, and guide this research. Figure 2. Disciplinary Lens
Literature Review 15
2.3 Social Marketing Lens
Social marking is the first lens of this thesis and provides insight on behavior. Evolving from social advertising and communication in the 1970’s, health social marketing focuses on behaviour change by influences consumers to either accept, reject, modify or abandon behaviors for social good (Rothschild, 1999). The behavioural change must be voluntary in nature and thus consumers must be willing to exert some sort of effort (Russell-Bennett, Previte, & Zainuddin, 2009; Vargo, Maglio, & Akaka, 2008). This effort whether perceived or real is where the process of value though exchange occurs. The exchange may be positive or negative in nature and it is the balancing and leveraging of tradeoffs that enables social value creation through the exchange of social offerings (French & Russell-Bennett, 2015). The left circle of Figure 2 demonstrates the eight benchmark criteria that need to be included for an intervention to be considered social marketing; behaviour, customer orientation, theory, insight, exchange, competition, segmentation and mixed methods (French & Blair-Stevens, 2006). These criteria are not a check list but rather an integrated set of concepts that support better understanding of core social marketing concepts, promote a consistent approach to review and evaluate interventions and to assist in the commissioning of social marketing services (Application in Appendix B).
2.3.1 Social Products and Services This thesis applies the core concept of value creation to HMA sexual behaviour through exploring the social offering and exchange that occurs between individuals that engage in protective sexual behaviour (Dann, 2010). This social offering can be in the form of ideas, products, service, experience, environments and systems that enables prophylactic condom use. Roberto and Kotler (1989) demonstrates this social offering through their conceptualisation of the “social product” model. They propose that ideas and behaviours, such as prophylactic condom use, can be marketed via three types of social product: social idea (beliefs, attitudes and values), social practice (act and behaviour) and tangible product (male condom). It should be noted that while Kotler and Roberto’s concept termed “social product” this is inclusive of sexual health services. In line with Vargo and Lusch (2008) Service Dominant (SD) Logic , services are the fundamental basis of exchange and all products are considered services as they provide value through their use (Vargo & Lusch, 2008). An application of this approach to the social product to protective sexual behaviour is shown in Figure 3.
16 Literature Review
Figure 3. Application of Social Marketing Offering to Protective Sexual Belief Condom's reduce sexual pleasure Attitude Idea I hate condoms Value Contraception is a woman's job Act Practice Going to a clinic for STI testing Behaviour
Using a condom with all parntenrs Marketing Offering Offering Marketing Tangible
Protective Sexual Behaviour Protective Male & female condoms, dental Social Social dams, lubricants, STI testing kits Offering Intangible Sexual health clinic services
Behaviour
Adapted using (Roberto & Kotler, 1989; Vargo et al., 2008)
2.4 Sexual Health Lens
The second lens for this thesis is sexual health. Sexual health is a fluid concept that is holistic in nature and it aims to understand the biological, psychological and sociocultural factors of human sex and sexuality to improve quality of life for individuals and society (Temple-Smith, 2014). Sexual health falls under the overarching discipline of Public Health that focuses on the social and environmental determinants of population health. The disciplines aim is to elucidate biological, behavioural, and psychosocial processes that operate across an individual’s life course, or across generations, to influence the development of disease risk to reduce morbidity and mortality within the population (Cabaj, Musto, & Ghali, 2019; WHO, 1986).
2.4.1 Globalisation of Sexual Health The first technical document for sexual health was written in 1975 by The World Health Organisation (WHO) and focused on sexual and reproductive rights (WHO, 1975). The primary aim of this document was the collection and use of epidemiological data to address maternal and infant morbidity and mortality and the
Literature Review 17
development more practical and effective venereal and treponematosis (syphilis) interventions (WHO, 1975). By the 1980s the combined burden of the HIV pandemic, increases in unwanted pregnancies, greater awareness of sexual violence and publicity about sexual disorders and dysfunctions placed mounting pressure for global sexual health promotion interventions. Initial efforts were guided by the OTTWA charter (Figure 4) which was developed by the WHO in 1986 as a way to ensure a holistic and comprehensive approach of promoting health to address social determinants and improve population health (WHO, 1986). The charter comprises of three core strategies (advocate, enable and mediate) and five action areas (developing personal skills, creating supportive environments, strengthening community action, reorienting health services, and building healthy public policy) (Application in Appendix C).
Figure 4. The Ottawa Charter
Adapted from The World Health Organization 1986
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2.4.2 Conceptualization of Sexual and Reproductive Health While the Ottawa Charter is recognised as the foundational document for health promotion interventions and has been applied to numerous behaviours across different populations, the complexity of sexual and reproductive health required its own framework (Potvin & Jones, 2011; WHO, 2006). As previously stated, the first technical document primarily focused on sexual and reproductive rights. While these sex and reproduction are closely linked crucial aspects of sexual health can be overlooked when grouped together with reproductive health. This is especially significant as HMAs are past the reproductive stage in their life interventions that focus on protection against pregnancy and STIs may be disregarded. To ensure interventions, programs and health services are equally aimed at sexual and reproductive health, WHO in 2017 published Sexual health and its links to reproductive health: an operational approach. This document provided a new framework that aims to operationalize the working definition of sexual health:
“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” (WHO, 2006).
The framework (Figure 5) is depicted visually as a rosette and has three levels: foundation of grounding principles, rosettes of sexual health and reproductive health interventions and the climate of social-structural factors. At the centre of the graphic is the overall objective of sexual health: the attainment of physical, emotional, mental and social well-being in ration to sexuality (WHO, 2017a). The grounding principles are at the bottom of the graphic and were listed in Figure 2.
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Figure 5. Sexual Health: an operational approach
Source: World Health Organisation 2017
Sexual health interventions (blue) and reproductive health interventions (orange) are depicted in contracting colours to show while distinct they are inextricably linked. Finally, the shading surrounding the graphic represents the existing cultural, socioeconomic, geopolitical and legal environments that form the contexts in which people live and influence sexual health interventions and outcomes. This framework has been applied to the context of this research in Table 2. Reproductive interventions have been excluded as most HMAs are past this stage in their life.
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Table 2. Application of Operational Approach to HMA Sexual Health
Framework Application to HMA Protective Sexual Behaviour
Cultural & social norms around The cultural and social norms surrounding HMA sexuality sexuality & the context in which it developed across their life course needs to be acknowledged. Gender & socioeconomic HMAs have distinct male & female gender roles from social inequality conditioning & historical events. Human rights
existing existing factors Interventions must ensure that all human rights are met. - Laws, policies, regulations & Interventions, services & products aimed at increasing Pre strategies HMA condom use have observe laws, policies, regulations & strategies. Holistic Approach HMA condom use interventions have to address the physical, emotional, mental & social aspects of sex & sexuality.
Linked nature of sexual & Acknowledging reproductive past & implications this has reproductive health on current & future sexual health. Respect, protection & fulfilment All interventions need to endure the protection & fulfilment of human rights of HMA human rights. Multilevel influences of sexual Interventions need to address the environmental, social & health individual levels of sexuality to ensure the physical, emotional, mental & social aspects of sexual health. Diversity of needs across life HMAs have different needs to younger populations & are GroundingPrinciples course & populations contextualised by their sexual experiences with/without condom use over their life course. Evidence based, respectful & Interventions to increase condom use in HMAs must be positive approach based on evidence & be both positive and respectful.
Sexual function & psychosexual Interventions need to address the impact condoms have on counselling ons sexual functioning for HMAs. Psychosexual counselling should also be incorporated & used to provide insights. Comprehensive education & Interventions need to provide education & information on information correct & consistent condom use including how to source, purchase, apply, use &dispose of condoms correctly. Gender based violence, This is an important strategy but outside the scope if this prevention, support & care thesis.
Prevention & control of HIV & Interventions aimed HMA condom use must address both Sexual Interventi Health other STIs prevention & control of transmission.
2.5 In Bed Together: Social Marketing and Sexual Health
The social marketing and sexual health disciplines are complementary to each other and underpin this research. They both share the common goal of encouraging behavioral change for individual and social good and are underpinned by theory and best practice. Using a social marking lenses will gain understanding of the product (condom) and the value that is derived from its use in HMA sexual encounters. It furthermore sheds light on the exchange that occurs within the specific behavior itself
Literature Review 21
by both male and female consumers. Using a social marketing lens also enables the strategic segmentation and targeting of heterosexual mature adults. While there is still need for sexual health interventions across the spectrum of mature adult sexuality (lesbian, gay, bisexual, transgender, intersex or queer) this is outside the scope of this thesis as condoms use does not have the same polarizing duality in product nature as for heterosexual consumer; contraceptive and prophylactic.
While the social marketing lens is strategic the sexual heath lens is used to holistically analyze sexual behavior and the biopsychosocial context in which it is performed (Suls & Rothman, 2004). The sexual health lens acknowledges the cultural and social norms of sexual behaviours, gender and historical contexts in which these norms have been formed. It also encompasses the social determinants of health behaviors and the impact these have on individual and population morbidity and mortality. The commonalities and differences between the social marketing and sexual health lens has been conceptualised in Figure 6.
Figure 6. Social Marketing and Sexual Health Commonalities & Differences
2.6 Social Marketing Campaigns for Sexual Health
The male latex condom is a simple product that has evolved over time but the behavior in which it is used is physically, emotionally, and socially complex. With an aging population and mounting pressure on our already strained health systems, the need for effective and efficient behavioral interventions has never been more vital (Marquez, Bustamante, Blissmer, & Prohaska, 2009). While there is a body of literature on the positive impact sex and sexuality has on quality of life, there is little
22 Literature Review
research or campaigns specifically focused at protective sexual behaviors in mature adults (DeLamater & Koepsel, 2015; Marshall, 2011). When protective sexual behaviours are explored in mature target markets it is generally part of a broader censes/retrospective study to identify the prevalence of disuses or focus on homosexuals (men who have sex with men) mature adults who are living with or at risk of contracting HIV/AIDS (Levy, 2002; Smith, 2011). Table 3 summaries the literature on social marketing campaigns focused at sexual health behaviours and illustrates the absence of campaigns targeted at heterosexual mature adults.
Table 3. Social Marketing Campaigns
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The absence of empirical studies and social marketing campaigns targeted at HMAs highlights a significant gap within both practice and the literature. As seen in table 3 social marketing campaigns are contextualised by high risk, youth and homosexual consumer markets. As sexual behaviours are highly complex and contextualised by the target population a sociology and anthropology view is needed to understand the intricacy of HMA sexual behaviour and how they have been developed.
The following section will discuss the thematic and chorological evolution of the field of sexology to sexual health, Early Civilization, The Renaissance, Industrial Age, Technological Age & Experience Age. This has been conceptualised from the psychology, public health, anthropology, medicine, and sexuality literature. Flowing this discussion, the development, and innovations in the protective sexual behaviour of sheathing the penis is discussed using the same conceptual evolution demonstrating the enduring duality in product nature: contraceptive and prophylactic.
2.7 From Sexology to Sexual Health: An Experiential Perspective
Research on sexuality has developed from a limited field dominated primarily by biomedical and sociological inquiry to the rigorous examination of biopsychosocial factors across a wide range of social sciences (Aggleton, 2010; DeLamater & Koepsel, 2015). Sexuality is a core dimension of being human and is the result of interplaying biological, psychological, socioeconomic, cultural, ethical and religious/spiritual factors (Foucault, 1990). These factors influence the individual and the social capabilities and conditions for eroticism, attachment, love, sex, gender and reproduction. Changes in the understanding of sexuality has brought about the reorientation of clinical and professional practice and has transformed the field of sexology to the broader more holistic field of sexual health.
Understanding the historical development of this field is paramount to future research and the positioning of this thesis. Figure 7 outlines the chronological and thematic development of sexuality research: Early Civilization, The Renaissance, Industrial Age, Technological Age & Experience Age. This progression has been conceptualised through the synthesis of psychology, public health, anthropology, medicine, and sexuality literature. There has been evolution in the nature of sexual experiences and a modern approach to understanding sexual behaviour must
24 Literature Review
incorporate the distant past. The sexual practices and beliefs evident today are a combination of contemporary and historical psycho-social beliefs and norms which results in misalignment and seemingly paradoxical behaviours by modern consumers. These paradoxes in behaviour are the trigger for social marketing and sexual health behavioural change campaigns.
Figure 7. Chronological Development of Sexuality Research
The Industrial Technological Experience Early Civilization Renaissance Age Age Age
Sexual Male Sexual Paraphilic Orgasm & Vibrators & Toys Dysfunction Organs Disorders Erogenous Zones Pharmaceuticals
Fertility Female Sexual Homosexuality Sexuality Scales Anatomy Anatomy
Deviance Deviance Sextech- sex Liberation Liberation
Organs Fulfillment
Exploration Erotic Experience Adultery Pornography Robots & Prostitution Repoduction Feminist & Gay Teledildonics Rights
2.7.1 Early Civilization and Sexual Exploration Enquiry into sexuality began in our earliest civilizations however the focus and definition of the term within these cultures varies drastically from the one we hold today (Halperin, 1989). Ancient sexual attitudes and behaviours were focused on the sexual experience rather than the current western holistic approach to sexuality, health, and fulfilment. Three common themes from reviewing anthropological and sociological literature on ancient sexuality highlighted the exploration of male sexual dysfunction and female fertility, erotic experiences, and the role of prostitution/courtesans. Ancient Greeks and Romans in particular were known to explore the physical and biological causes of male sexual dysfunction attributing the affliction to physical exertion, infirmity, old age and spiritual or mystical intervention (Berry, 2013a). Cures for such “potency problems” included rhinoceros horn, Spanish fly, mandrake root as well as talismans that have magical properties or appease the gods (Taberner, 2012). This notation of the role of magic and gods regarding fertility and function transcended across Mesopotamian, Egyptian, Mayan, Chinese, Aztec and Incan civilisations (Mirecki, 2001). The role of the goddess and creation of life influenced beliefs around reproduction and partly explains the enduring historical assumption of infertility being a women’s fault.
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Erotic experiences were the second theme identified in early civilisations exploration of sex. The Greeks identified the difference between sex for procreation (work) and erotic activity (play). Just like farmer must labour on the land to produce crops, so must a husband labour with his wife to produce offspring (Halperin, Winkler, & Zeitlin, 1990). This differed greatly from erotic play which may have included premarital, extramarital, homosexual and even martial sexual activity as long as it was for pleasure not for the purpose of producing a child (Halperin et al., 1990). This concept was also evident in the Kamasutra which is an ancient Indian dissertation on bodily pleasures and social norms from approximately the 4th century (Burton, 2004; Daniélou, 1993). The Kamasutra focuses on the erotic experience and the art of living, finding a partner, maintaining power in a marriage, committing adultery, living as or with a courtesan and using drugs (Doniger, 2002).
The role women and prostitution were the final theme identified in the sex literature. The term encompasses a wide range of female sexual roles across civilizations dependent on social status, political power and divinity. The most common terms where courtesan, mistress companion, priestesses, temple, street or indentured prostitute and whore (Gilmore, 1998). While civilization and understanding of sexuality has moved beyond primitive notions of magic, religion, fertility, dysfunctions and eroticism these cultural beliefs and practises formed the foundations of sexuality studies.
2.7.2 The Renaissance and Sexual Anatomy The fall of the Roman Empire and rise of religious oppression during the “dark ages” saw a halt to scientific and sociological enquiry into sex and sexuality. The church became responsible for prescribing what sexual acts people might indulge in and regulating where, when, and with whom sex could take place (Richards, 2013). It wasn’t until the renaissance in the 15th century that sex came back to the forefront of science with a focus on the physical anatomy and functioning of sexual organ. The advancement of information technology through the printing press saw the demand for the dissemination of accurate information on the human body within the medical field (Malomo, Idowu, & Osuagwu, 2006). Public and private dissections of human and animal bodies known as anatomical theatre became increasingly popular (Klestinec, 2011). However, the dissection and manipulation of urinary and reproductive systems were only performed for and by anatomy students in their final year of study. Andreas
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Vesalius known as the father of anatomy whose illustrative text De humani corporis fabrics (On the workings of the human body) became the authoritative text for two centuries (Singh, 2014).
Anatomy was not only for medical students with artists also taking an interest in the reproductive system and sexual organs. Leonardo da Vinci was undoubtedly the most industrious artist, producing hundreds of anatomical drawings. He was the first author to describe the increased blood inflow to the penis as the cause of erection after his own observations and dissections in human corpses (Schultheiss & Glina, 2010). The focus on the penis and male erections was continued by Dutch physician Regnier de Graaf who succeeded in causing an erection in a corpse by injecting water into the hypogastric artery (Schultheiss & Glina, 2010). In comparison to penial anatomy female sexual organs received less scholarly attention (O'Connell, Sanjeevan, & Hutson, 2005). Gabriello Fallopio was considered the first anatomist to accurately describe the human oviduct which he renamed the fallopian tubes (Malomo et al., 2006; Speert, 1955). Fallopio has also been attributed with discovering the clitoris however there is some contention over this as Regnier de Graaf outlined the muscles, vascular and nerve supply of the clitoris and confirmed its function as “exquisite sensitivity to pleasure and passion” in the mid-1600s (Stringer and Becker, 2010). Despite these early reports, the clitoris was often ignored or misrepresented in anatomical descriptions during subsequent centuries with Vesalius himself arguing against the existence of the citreous in normal women (Pauls, 2015). When the clitoris was discussed by scholars it was often by comparison to the penis or as a “passive and unimportant” structure (O'Connell et al., 2005).
It is during the renaissance and study of human anatomy that we see the social construction emphasizing the importance of male sexual pleasure while framing female pleasure as irrelevant and anatomical structure that allow female pleasure were also seen to be abnormal. With exploration and understanding of human anatomical structure and functioning scholarly work moved towards the mind and psychology of deviant sexual behaviours.
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2.7.3 Industrial Age and Sexual Deviance Scientific enquiry into sexology beyond anatomy emerged at the turn of the 19th century with the work of Freud and Ellis on psychosexual development, sexual drive and sexual dysfunction (Ellis, 1936; Freud, 1953). This nascent stage was contextualised by a strict sexual morality and female inequality echoing propositions of anatomical theatre. Psychological studies began with the exploration of sexual deviance (paraphilic disorders, homosexuality and extra martial sex) in order to understand the enduring conflict between sexual impulses and restraint of these urges (Ellis, 1936; Freud, 1953). Freud in particular set the tone with his publication "Drei Abhandlungen zur Sexualtheorie” (Three Contributions to the Sexual Theory) in 1905 theorising that sexual drive is a large factor in determining an individual’s psychology starting from infancy (Freud, 1953).
Freud’s first contribution explored sexual aberrations in the form of perversion. Freud proposes the parallel between man’s sexual need (sexual instinct) and hunger. This hunger is termed libido and in satisfying this need aberration can occur at the “sexual object” person from whom the sexual attraction emanates and or the “sexual aim” which is the action towards which the impulse strives (Freud, 2012). Aberration and deviation occurring within the sexual object is described as inversion (homosexuality) and is assumed to be an acquired characteristic with only the most extreme cases being innate. He also discussed sexual inverts whose sexual objects do not belong to normally adapted sex and manifests in the sexual attraction to the sexually immature (paedophiles) and sexual attraction to animals (bestiality)(Freud, 1953). The second half of this contribution regarded the sexual aim whereby there is deviation between the unions of genitals in the act of copulation. This may take form as either an anatomical transgression of the bodily regions destined for sexual union or a lingering on what should normally be rapidly passed to achieve the sexual aim. In other words, his work explored variations in the manifestation of sexual behaviours and potential links to neurosis and perversion. These behaviours included oral and membrane fixation , anal openings, erogenous zones, fetishes, fondling, voyeurism, sadism and masochism (Freud, 1953).
Freud’s second contribution was concerning infantile sexuality. Prior to his work children were believed to be innocent or pure with no sexual impulses or behaviours (Chodoff, 1966). The concepts of infantile psychosexuality explored infantile genital
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behaviour, childhood sexual activity, non-genital gratification (thumb sucking), fantasies and other mental activities. While Freud did not provide a clear definition of child sexuality the essay did provide observations concepts and constructs that broadened his theory of sexuality beyond genital behaviour alone (Chodoff, 1966). Freud’s final contribution focused on puberty, masturbation and proposed fore- pleasure, end-pleasure and libido theory. He also pointed out the differences between male and female puberty and the development of inhibitions such as shame. These two contributions were aimed at exploring how sexuality develops and how these experience and fixations can be inverted resulting in the aberrations discussed in the first contribution.
After the publication of his essays Freud stated to explore femininity and female hysteria. His controversial lecture in 1933 entitled “Femininity” proposed the theory of “Penis Envy” (Freud, 1933). This theory states that females become envious of penises as children and this envy manifests as a daughters love for her father and the desire to birth a son as this is as close as she will get to a penis of her own (Freud, 1933). Freud was also know to say that that women would never achieve social equality with men due the limitations of marital and reproductive roles (Boyer, 1978). Although few modern psychoanalysts emphasise the role of penis envy in female psychology it is still regarded by some as a clinical fact despite the controversy around its validity, etiology and significance (Jones, 1994). Controversial as Freudian theories may have been, they set the tone for sexuality research, pushed the boundaries and tackled the taboos of sex. Freud’s work paved the way for Kinsey, Masters and Johnsen whose unorthodox methods echoed the liberation and social change of the 1960’s and 1970’s.
2.7.4 Technological Age and Sexual Liberation With deviant behaviour thoroughly explored the modernisation of sex and sexuality began (Kinsey, Pomeroy, & Martin, 2003a). Alfred Kinsey’s cumulative work on normative sexual behaviour in males and females challenged many of societies beliefs and is considered as a catalysts for the sexual revolution and feminist, gay and lesbian movements of the 1960’s and 70’s (Berry, 2013b). Kinsey’s sexuality scale which ranged from 0-6 challenged beliefs and demonstrate the complexity of human sexuality (Drucker, 2010; Kinsey, Pomeroy, & Martin, 2003b). While there has been debate over potentials biases within the sample the idea that human sexuality is
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a continuum rather than binary in nature still hold true today (Cochran, Mosteller, & Tukey, 1953; Maslow & Sakoda, 1952). Another of Kinsey’s most renowned propositions was that women were sexual beings deifying scientific discourse of the time (Bullough, 1998; Gagnon, 1975). As previously discussed, anatomists and psychoanalysts had diminished the importance of female sexuality and pleasure, but this was all about to change.
Masters and Johnson’s further challenged society and academia through the direct observation and measurement of human sexual response of 694 volunteers in a laboratory setting (Masters & Johnson, 1966; Masters, Johnson, Kolodny, & Bergen, 1995). From this they developed the human sexual response cycle which includes four sages: excitement (reaction to sexual stimuli), plateau (intensified arousal), orgasm (release of built up muscle tension accompanied by intense pleasurable sensations) and resolution (body returns to a sexually unstimulated state). Research was criticised, the criticism focused much more on their research methods than their research findings (Morrow, 2008). The results of this research were a greater understanding of the human body in regard to pleasure and this combined with pressure from social movements saw the demise of the traditional model of sexual restraint. This was only exacerbated by the introduction of the pill as a contraceptive giving women power of their reproductive cycles (Goldin & Katz, 2002). From these advancements a new moral economy emerged where sex was separate from reproduction, marriage, parenting and heterosexuality (Cook, 2004; McLaren, 1999).
Liberation of sexual activity from reproduction and traditional marital relationships allowed for the break through work on Sexual Scripting (Simon & Gagnon, 1986). Sexual scripting allowed the conceptualisation of response behaviours by connecting an individual’s development with accompanying social pressures making biological events secondary to narrative (Aggleton, 2010; Simon, 1994; Simon & Gagnon, 1984). Application of sexual scripting has successful been used to understand condom use, sexual dysfunction treatment and sexual and gender identities issues that have become more prevalent within society (Štulhofer, Buško, & Landripet, 2010a; Wiederman, 2005a). HIV (human immune deficiency virus) was a global concern within this era as it was untreatable resulting in substantial health and economic impacts. HIV is a lentivirus which can lead to acquired immune deficiency syndrome (AIDS) or as it was first coined GRID (gay related immune deficiency). The
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first identified cases of HIV at the time were within men who had sex with men and as such the greatest impact of the epidemic was amongst this population and racial/ethnic minorities (Chin, 1990). Interventions focused on extensive sexuality education, STI and HIV pre- and post-test counselling, safer sex/risk reduction counselling and condom promotion (WHO, 2006). Unfortunately, lack of public awareness, lack of training of health workers and long-standing widespread stigma around STIs remained a barrier to the effective use of sexual health interventions within this era. As stated in the sexual health theoretical lens the HIV epidemic made sexual health synonymous with public health and as such the determinants of sexual health for youth and homosexual markets became the predominate focus of behavioural interventions and research within the social sciences.
2.7.5 Experience Age and Sexual Fulfilment Following the HIV epidemic biomedical, pharmaceutical and psychosocial dimensions of sexuality research focused on the treatment and eradication of sexually communicable diseases and sexual dysfunctions to create/prolong individual’s sexual health. Sexuality and sexual activity are intrinsic to quality of life and we have moved beyond being sexually liberated to wanting sexual fulfilment. There is debate over the future agenda of sexual health research however scholars maintain that quality of life and wellbeing will always be the fundamental goal (Aggleton & Parker, 2010; WHO, 2006). Proposed areas for the experience age have included the importance of sexual pleasure and wellbeing, technological advancements in sex toys, dolls, virtual reality and robots, institutional and policy development and sexuality across life course needs a collaborative effort in the form of linked parallel research initiatives across theoretical methodological and contextual divides (Aggleton & Parker, 2010; Döring, 2017; Koch, Mansfield, Thurau, & Carey, 2005).
This experience centric focus of sexual wellness and fulfilment is also evident in the sex toy industry which is predicated to grow globally by $9.9 billion between 2019 and 2023 (Burns, 2016; Technavio, 2020). “Sex toys” is an umbrella term that incorporates objects that are designed to stimulate the body and induce pleasure and they are and no longer the province of sleazy urban sex shops and pornographers (McCaughey & French, 2001). The internet has expanded and diversified the market making sexual product more affordable and accessible (Daneback, Mansson, & Ross, 2011; Döring, Daneback, Shaughnessy, Grov, & Byers, 2017). As a society the taboos
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against sexual pleasure have diminished and in-home sex toy parties have even been paralleled to Tupperware parties (McCaughey & French, 2001). High-tech designer sex toys are now seen to contribute to fulfilling sexual experiences by enabling consumers to control physical pleasure and support intimacy between partners (Bardzell & Bardzell, 2011). The development of couple’s sex toys (couple vibrators and vibrating cock rings) has also commodified shared sexual pleasure and shifted the discourse of sex toys from perverted individual use to a product that adds experiential value to the customers sexual experience.
The experience age has also seen the development of sex tech and subcultures of “technosexuals” which refers to as people who have sexual interests in machines, robots, androids and other sexual devices (Cheok & Zhang, 2019; Hall, 2016). From a psychological point of view there is interest in technosexuals and whether they are sexually attracted to an android partner because it is a genuine machine or an android that is a transformation of a real person (Döring & Pöschl, 2018). This can be seen in the product real dolls which are an articulated skeleton made of steel, covered with artificial elastic flesh made of silicone. Other areas of research still involve human to human sexual activity but this is facilitated through the use of teledildonics which are devices that allow two people to engage in sexual interactions over a distance, usually via the internet (Döring & Pöschl, 2018). While interesting the use of sex tech is outside the scope of this thesis but should be acknowledged as it is part of the future agenda of sex and sexuality research.
2.7.6 The Modern Approach to Researching Sex The modern approach to studying sex is focused on understanding how to achieve physical, emotional, mental and social sexual fulfilment. It acknowledges the evolution of the field and scholarly enquiry form the past as paradoxes and remnants are still evident today. People still practice the Kamasutra (Doniger, 2002). Manufacturers of sex toys use the understanding of anatomical structures and human sexual response to develop product for example cock rings, flesh lights, sex dolls, vibrators, g-spot and clitoral stimulators (Bardzell & Bardzell, 2011). Prostitution and homosexuality are still seen as deviant and immoral by some despite roots and even divinity in ancient civilizations (Tan et al., 2019). Social movements have shaped our society and perception of gender role in relation to reproduction and
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opportunity (Stienstra, 2016). We cannot study modern sexual behaviour without acknowledging and building on the past.
This thesis is positioned to understand the sexual experiences of heterosexual mature adults aged 50 years or older. As life expectancy increases and we see a “greying” of the population there is significant need for sexuality research as it is experienced. Academics have acknowledged this gap and have stated that research needs to explore quality of life and health, the realities of aging and increasing reliance on pharmaceutical products and medical interventions for sexual health (Aggleton & Parker, 2010; DeLamater, 2012; Marshall, 2011). In particular the impacts of ageing in terms of the physical, mental and social deficits and compromise also need to be explored (Lindau et al., 2007; Penhollow, Young, & Denny, 2009). Like Freud, Kinsey, Master and Johnson this research continues to challenge societal beliefs and norms around sexuality. This research addresses the need for a greater understanding of the lived sexual experiences heterosexual mature adults.
2.8 Protective Sexual Behaviours: Sheathing the Penis
Protective sexual behaviours aim to reduce or prevent an individual’s risk of unwanted pregnancy and or contraction of a communicable sexuality transmitted disease through the exchange of fluids such as salvia, semen, vaginal fluids or blood (Centre for Disease Control and Prevention, 2016). Condoms are the most effective and promoted product for protection against STIs and as a contraceptive measure to prevent unplanned pregnancy. They are reliable, relatively inexpensive, light, compact and disposable, requires no medical examination, supervision or follow-up and have no side effects. Condoms also offer physical post-coital evidence of effectiveness, provides protection against STIs and empower males to share actively in planning his family. Just like sexuality research the condom and sheathing the penis has evolved and developed overtime. The following section will discuss the product development of the condom (Figure 8) using the thematic and chronological development of sexuality research discussed in the previous section. This section demonstrates the duality of the nature of the product: prophylactic and contraceptive.
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Figure 8. Product Development of the Condom
Silk, Horn & Linen & Rubber Latex Polyurethane Bladder Intestines
The Industrial Technological Experience Early Civilization Renaissance Age Age Age
2.8.1 Early civilisations: Silk, Horn and Bladder The condom dates to early civilizations with the first depiction of a sheath worn on a penis appearing in cave paintings that still exists in France dated at 15000 B.C (Chevallier & White, 1995). Sheathing of the penis within this era was prophylactic in nature and is believed to have begun as a method of protection against “evil spirits”, insect bites, sunburn and getting snagged on bushes (Parisot 1993). Materials commonly used included silk, oiled skins, linen, bladders and even shell or animal horn and ranged from full sheaths to glans condoms that just covered the tip of the penis. Egyptians were also documented as amongst the first to wear a protective sheath caps dyed different colours to distinguish social class and protect against bilharzia (parasitic flatworm) (Tatum & Connell-Tatum, 1981). There is also some evidence of ancient civilisations sheathing the penis for protection against disease. The earliest evidence seen in Greek writings of King Minos of Crete. He was said to have used a goats bladder in the vagina of his wife to protect her form the “scorpions and serpents” in his seaman that killed his mistress (Khan, Mukhtar, Dickinson, & Sriprasad, 2013). There are also similar accounts of Romans proposedly using bladders in orgies which was discovered during the Renaissance with the revival of ancient culture after the dark ages.
2.8.2 Renaissance: Linen and Intestines Little is known about condoms use during the dark ages (era between ancient civilisation and renaissance) except the Roman Catholic Church positioned them as contraceptive and condemned any form of use as sinful (Richards, 2013). It was not until the renaissance in the 15th and 16th centuries where art, science and sex
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flourished in Europe. Syphilis had become an epidemic and as previously discussed anatomy of the body and how it functioned was at the height of intellectual enquiry. Gabrielle Fallopio (discovered the fallopian tubes) in response to this conducted the first known trials of sheath effectiveness against sexually transmitted disease shifting perspective back to prophylactic. Published two years after his death in 1564 Fallopio claimed to have invented a linen sheaths prepared with herbs and salts for the paraphilic uses in a trial of 1,100 men of who none caught the disease (Brown, 1998; Youssef, 1993).
The use of animal intestines to cover the penis for protection from disease has been attributed to slaughterhouse workers of the time (Youssef, 1993). The original condoms were made from animal intestine (caecum) of sheep, calves and goats. While intestine transmitted sensation and body heat they had hand sewn seams and where relatively expensive (Youssef, 1993). It is not surprising that membranes form animals were experimented with as a penial sheath considering the focus on human and animal anatomical structures of the time. It is also within this ear that we see a shift in the primary use of condoms as a prophylactic to a contraceptive. The shift can be seen in the memoirs of one of history’s most notorious lovers Casanova who used to inflate every condom he used to check for holes. These memoirs describe the sizes and quality of the different types of “English overcoats” that he used for protection against pregnancy ("The Medical Interest Of Casanova's "Memoirs"," 1924; Quarini, 2005; Youssef, 1993). By the 18th century 'the condom', 'preservative machine', or 'armour' as it was variously described was popular for contraceptive as well as its prophylactic functions and was even widely praised in erotic poetry. Unfortunately condoms were only for those who could afford them and it wasn’t until the 1800’s that condoms became cheap and widely available (Quarini, 2005; Youssef, 1993).
2.8.3 Industrial Age: Rubber The industrial revolution saw the devolvement of vulcanising rubber by Hancock and Goodyear in 1844 (Youssef, 1993). This process involved heating sulphur and natural rubber together to form a malleable and durable material with high elasticity and tensile strength. This is where the colloquial term “rubbers” originated and soon after their production the ‘short sheath’ which only covered the glans (head) of the penis hit the market (Chowdhry, Jaiswal, D’Souza, & Dhali, 2019). The main problem with these two products was that they were custom made to fit and were as
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thick as a bicycle inner tube severely impacting the pleasure of men (Youssef, 1993). The benefits however were that they could be reused and as such were cheaper in the long run to their animal counterparts. Eventually manufactures realised they could mass produce a “one size fits all” using glass moulds at a much more reasonable cost. Although widely available there was still stigmatism towards condom use as they were predominantly used with brothels and by women of loose morals. It is here we can see that condom use by women brought about feelings of shame and guilt especially as objectors likened condom use to abortion. Despite this many married women still discreetly used rubber condoms due to anxiety over pregnancy (Chowdhry et al., 2019). Evidence of this can be found in the significant drop of birth rates across Europe form 1870- 1924. The average family size went from six children per family to two or three by World War I (Feichtinger, 2013).
Condoms made from animal membranes were slowly phased out as refinement and mass production of rubber condoms were made. By 1901 product development of the condom had resulted in a cheap, reusable, seamless rubber sheath with a teat-ended shape to hold ejaculate (Chowdhry et al., 2019). Condoms were no longer only for the wealthy and middle/low class families had contraceptive options beyond withdrawal or as Freud termed it “coitus interruptus” (McLaren, 1979). This was significant as sexual satisfaction and orgasm by any other mean than penial penetration of the female vagina was condemned. While Freud did not believe in female social equity, he was an advocate for female sexuality and recognised that coitus interruptus could be frustrating for females and may even lead to hysteria (McLaren, 1979). This reflected his understanding of the time as despite the anatomical discovery of the clitoris it was still assumed that females could only orgasm form vaginal stimulation. While Freud studies did not condemn condoms as deviant he did recognise that the thick rubber “enfeebled” the sexually of men, diminished their libido and were something that was forced upon them (McLaren, 1979). For this reason, rubber was fairly short lived in comparison to its product history. Innovation of liquid latex was the next advancement in the condom transforming condoms into what they are today.
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2.8.4 Technological Age: Latex Latex is formed when emulsified rubber is dispersed in water. This technique was developed in the 1930’s and resulted in a product that was more reliable, had a longer shelf life (5 years vs 3 months) and performed better for the consumer as it was thinner and stronger than the rubber predecessors. World War II saw an increased production of condoms and repositioned them as a prophylactic in the public eye. Both Allied and Axis forces attempted to prevent their troops from contracting what was then known as venereal diseases (VD). Soldiers were provided with free condoms as syphilis and gonorrhoea were a primary concern. Treatment of gonorrhoea took 30 days and syphilis could take up to 6 months severely affecting the number of service men on hand (Stryker, 1993). Social advertising and propaganda were the primary from of encouraging behavioural change by playing on soldiers’ sense of duty while villainising women as spreading VD. This obviously worked as armed forces produced substantial increases in condom sales with the annual industry sales growing to approximately $300 million (Boone & Kurtz, 1989). The responsibility of condom use was marketed at males and women were positioned as either good girls (virgins until marriage) or good time girls (promiscuous and unclean). By the end of WWII, the association between condoms and VD, the introduction of better treatments (penicillin) and social pressure to get married and settle down saw a decline in condom use. This is also when the first of HMAs (baby boomers) were born between 1946 and 1964 (Kumar & Lim, 2008).
Trying to move away from associations with VD condoms were repositioned by sexual health initiatives as “family planning” once again making them contraceptive rather than prophylactic in nature. Condom popularity was short lived however as “The Pill” disrupted the contraceptive market. Women gained reproductive freedom and control that could be discreetly managed outside male control. This combined with ideologies of free love, social movements for feminist and gay rights and studies into normal sexuality challenge deviant discourse forever labelled this era as the sexual revolution (Berry, 2013b). Condoms fought back by becoming lubricated, textured and even coloured to increase sales. There were even the first attempts into polyurethane however due to high rupture rates research was discontinued. Inevitably it was the AIDS epidemic that brought condoms back into the public eye.
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Acquired immune deficiency syndrome (AIDS) was first formally recognized in USA patients in 1981 with subsequent characterisation of the causative agent as human immunodeficiency virus (HIV) (Sharp & Hahn, 2010). Unresponsive to treatment and asymptomatic it carries fear and near hysteria spread throughout the public. Cases predominantly presented in homosexual men with secondary occurrences in bisexual men, IV drug abusers and blood donor populations. The infection rate within homosexual men was disproportionate to heterosexuals as unprotected receptive anal sex allowed for direct exposure of infected semen to mucus membranes (Mueller, 1986). This presented a new public health challenge as homosexual men did not need to used condoms for contraceptive purposes. With the projected lifetime cost of treating AIDS at $80,000 per person, health promotion efforts focused on increasing condom use in homosexual men (Bloom & Carliner, 1988). This is evident in the large body of literature of interventions and studies to identify determinates of condom use in homosexual men (Feldman, 1989; Holtgrave & Kelly, 1997; Kegeles, Hays, & Coates, 1996; McKusick et al., 1985; Stokes, Vanable, & McKirnan, 1997). While this instilled a strong association of prophylactic use within homosexual men, HMAs who were aged between 17 and 35 may have missed and or ignored this communication retaining early notions of propaganda and fear. One good thing to come out of the AIDS epidemic was more stringent product testing, however it should be acknowledged that testing was always in relation to product failure and pregnancy not transmission of disease (Stryker, 1993). Once again this demonstrates the duality in product nature.
2.8.5 Experience Age: Polyurethane The next product evolution form latex was polyurethane in 1994 (Chowdhry et al., 2019). The kinks from the 60’s had been worked out and as polyurethane condoms transmit heat, they feel more natural/pleasurable. Polyurethane can also be used with mineral oil lubricants that deteriorates latex and provides an option for the increasing amount of people who have a latex allergy. The experience of condom usage has become the primary focus of condom product development. In the pursuit of “safe” sexual fulfilment condom now come in; smooth (lubricated or nonlubricated) latex, studded, textured, coloured, flavoured, warming, tingling, pleasure shaped and glow in the dark to name a few (spafe, 2019). There has even been a resurgence of “lambskin” condoms however these come with a warning as they do not protect against
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STIs and are not as effective as latex for pregnancy (Trojan, 2016). One thing that all these condoms have in common is that they at trying to create an experience. This experience is one that either simulates condom less sex and the user is unaware of product usage or the complete opposite where the product is complementary and enhances the sexual experience.
Need for innovation in this space has been recognised by the Bill and Melinda gates foundation. In 2013 they called for the development of the “next generation of condoms” of which 22 grants were awarded ("Develop the Next Generation of Condom," 2013). Successful applications had to be safe and effective, but most importantly preserve the pleasure of the user. The successful applications designs are still in development and are utilising materials that are still being explored by the scientific community including graphene, nano-fabrics and hydrogels ("Develop the Next Generation of Condom," 2013). Focusing on the experiential elements of a product emphasises the need for research on the lived experiences of condom usage and the experiential elements of the protective behaviour.
2.9 The Condom: Contraception or Prophylactic?
Through discussing the evolution of condoms there is clear duality in the nature of the product: prophylactic and contraceptive. The positioning of this nature has been dependent upon the historical context, social norms and target market of the time. While the product itself is simple the context of its behavioural use is complex. Successful use of a condom for both prophylactic and contraceptive purposes is dependent upon the correct orchestration of multiple factors such as planning, purchase, storage, transportation, negotiation, application, use, removal and disposal (Crosby, Sanders, Yarber, Graham, & Dodge, 2002). And this is just within the sexual act itself, the contextual aspects of use such as relationship type, gender role and past sexual experiences all play their part. This complexity is reflected in the literature with large bodies of work on the determinants of condom use. These studies have typically focused on populations that are high risk such as sex workers, men who have sex with men, adolescents/young people and people who are HIV positive (Adih & Alexander, 1999; Helweg-Larsen & Collins, 1994; Kingsley et al., 1987).
When we look at the literature specifically focused on HMA condom use behaviour it is in regards to them not using condoms due to a lack of skills or
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knowledge, limited risk perceptions and menopausal changes (Maes & Louis, 2003; Strombeck & Levy, 1998).When HMA condom use is studied they are not representative within the sample and are only part of the research if it is a national survey or retrospective cohort study. This can be seen in Sheeran, Abraham, and Orbell (1999) systematic review on the correlates of condom use among heterosexual samples. They conducted a meta-analysis to quantify the relationship between psychosocial variables and self-reported condom use. Upon review of 121 empirical studies only 9 papers included participants over the age of 50 within their sample (Bajos et al., 1995; Dolcini et al., 1993; Fishbein et al., 1995; Lagarde, Pison, & Enel, 1996; Leigh, Temple, & Trocki, 1993; Paul et al., 1995; Sikkema et al., 1996; Soskolne, Maayan, & Dormoi, 1993; Uitenbroek, 1994). Insights on heterosexual condom use from their analysis did not consider mature adults however they did suggest that early intervention and proper condom use is needed in “older people” (Sheeran et al., 1999). Many scholars have echoed this need for further research on mature adults and condom use behaviour (Marshall, 2011; Schick et al., 2010; Somes & Donatelli, 2012; Taylor & Gosney, 2011). Social marketing and sexual health interventions both require evidence and theory to develop successful behavioural intervention strategies. There is a clear need for qualitative research to explore protective sexual behaviours in heterosexual mature adults.
2.10 Heterosexual Mature Adults Sex and Sexuality Literature
The study of sex and sexuality in HMAs began the early twenty first century with arguments to move beyond a medicalised model of dysfunction and sexual decline (DeLamater & Koepsel, 2015; Tiefer, 1996). This medicalised perspective had a strong focus on dysfunction, illness and treatment emphasising stereotypes of sexual decline with age. These studies focused primarily on the negative dimensions of sexual activity such as erectile dysfunction, hormone imbalances, pain and dissatisfaction (Tiefer, 1996). This is because sexual activity and function were believed to largely depend on psychological, pharmacological, and illness-related factors (Meston, 1997). While ageing can impact sexual activity through issues like erectile and lubrication difficulties it should not be the only focus of sex research in mature age consumers (Laumann, Glasser, Neves, & Moreira , 2009). The shift to a positive sexuality framework began with challenging societal perception of an “asexual’ old age by profiling the prevalence, frequency and type of sexual activity occurring in HMAs
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(DeLamater & Moorman, 2007; Marshall, 2011; Schick et al., 2010). The link between these activities, positive health and quality of life has formed the body of sex and sexuality literature in HMAs.
2.10.1 HMA Sexuality and Quality of life Quality of life (QOL) is a complex concept related to personal dimensions such as physical functioning, perceived health, social relationships and psychological well- being that change over time (Robinson & Molzahn, 2007). Sexuality QOL studies began by acknowledging the benefits of physical and sexual experiences in HMAs. Framed in the public health, gerontology and nursing fields types of sexual experiences and activities were explored such as touching, holding hands, embracing, hugging, kissing, mutual stroking, masturbation, partnered masturbation, oral sex, penial- vaginal intercourse and anal intercourse (Brody, 2010; Ginsberg, Pomerantz, & Kramer-Feeley, 2005). These sexual activities were then linked in subsequent studies to positive health outcome and quality of life (Bauer, Haesler, & Fetherstonhaugh, 2016; Brody, 2010; Ginsberg, Pomerantz, & Kramer-Feeley, 2005b; Gott & Hinchliff, 2003; Hillman, 2011; Marshall, 2011; Robinson & Molzahn, 2007).
DeLamater (2002) conceptualised this change through his biopsychosocial approach to sexuality. This differed from previous studies as it proposed the analysis of sexuality over the life course of an individual and therefore biology (physical and mental health) is only considered as one of the factors influencing sexuality (DeLamater, 2002, 2012). A biopsychosocial perspective includes the psychological influences (knowledge, attitudes), relationship characteristics (quality, satisfaction) and sexual function (desire, dysfunction, treatment) as part of the examination of sexuality in mature adults (DeLamater, 2012; DeLamater & Sill, 2005). Studies using this framework have helped proved that men and women remain sexually active well into their 80’s (Lindau et al., 2007; Marshall, 2011). That aging related physical changes do not necessarily lead to a decline in sexual function (Rheaume & Mitty, 2008; Somes & Donatelli, 2012) . Sexual activity is likely to continue in mature adults if they have good physical and mental health, positive attitudes toward sex in later life and access to a healthy partner (Carpenter et al., 2006; Carr, 2004; DeLamater & Koepsel, 2015). Even though the link between sexual activity and quality of life in mature adults have been empirically linked there is still taboo around speaking about aging and sexuality. This has extended into the medical field with health practitioners
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misdiagnosing or ignoring sexual concerns in their mature patients as they are unprepared/untrained for these discussions and or believe stereotypes of sexless old age (Hodson & Skeen, 1994; Taylor & Gosney, 2011).
2.10.2 HMA Sexual Health Communication General practitioners (GPs) are many people’s first point of contact when they have health concerns. They provide treatment of short-term illness, preventative health practices and manage long term health conditions. As engagement with GPs increase as we age the second body of literature around communication of sex and sexuality between GP and HMA has emerged (ABS, 2016). While it has been established that sexual activity impacts quality of life and is an important factor in healthy aging, general practitioners (GPs) do not proactively engage in discussions regarding the sexual health of their mature patients (Bauer et al., 2016; Farrell & Belza, 2012; Gott, Hinchliff, & Galena, 2004). Safe sex is not seen as appropriate or relevant to mature adults with many GPs feeling that sexual discussion are “prying” (Gott et al., 2004). They do however acknowledge the theoretical significance of sexuality and believe it is important to discuss sex with their mature patients. Despite this many admit to being reactive rather than proactive in these discussions as the feel that factors such as age and gender differences, complexity from comorbidities and their doctor-patient relationship were inhibiters (Bauer et al., 2016; Malta et al., 2018). Societal influences on clinical practices through stereotypes of aging and the belief that only young people engage in risky sexual behaviours also proved to be a reason why GPs did not engage in these discussions (Bauer et al., 2016).
From the perspective of the mature patient, studies have found that many are reluctant to speak about their sexual health due to thinking their condition is “normal”, embarrassment, fear of negative reactions, dissatisfaction with treatment and seeming disinterest by health professionals (Gott et al., 2004). Mature adults also feared judgment in remaining sexually active especially when forming a new relationship after the death or divorce form a partner (Carr, 2004; Gott et al., 2004). To mature adults the GP’s role is one of power and legitimacy. Gott et al. (2004) identified that some mature adults perceive the GP as a ‘permission-granter’ or legitimizer of their sexual activity hence the fear of judgment and or negative reactions. The culmination of this research suggests that both health practitioners and mature adults need to be proactive in engaging in discussion around sex and sexual health. Practitioners need
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to view sex and sexuality as independent from biological age and create an environment that is nonjudgmental and informative. They also need to be trained and provided with the tools and insight to promote and educate HMAs on condom use.
2.10.3 HMA Sex and Sexuality: Call for future research The shift to a biopsychosocial prospective of sexuality has seen research into and beyond the prevalence and type of sexual activities prevalent in HMAs. There is a large body of literature linking sexual activity to positive health outcomes and QOL (Gott & Hinchliff, 2003). With the rising cost of health and social support for an aging population the need for preventative interventions addressing determinates of sexual health has never been more vital (Marquez et al., 2009). Despite this GPs state they are not proactive with their patients sexual health due to feeling untrained and or underqualified in this area (Bauer et al., 2016; Malta et al., 2018). Synthesis of the literature identified the need to understand the lived experience of HMAs and how they navigate sexual experiences (Marshall, 2011). The “lived experience” is a common term used in health and psychology phenomenological studies (Van Manen, 2016) The lived experience refers to the experiences and choices made by an individual and the subsequent knowledge or outcomes gained from these experiences. The collective outcomes from an individual’s lived experiences form a phenomenological archive by which they cognitively retrieve information to help them navigate similar situations and make choices. Little is known about the lived sexual experiences of HMAs and their experiences and their choices made around protective sexual behaviours.
Gap 1: We do not know the beliefs and attitudes related to condom use by heterosexual mature adults and how they navigate protective sexual behaviours.
2.11 Theoretical framework 1- Sexual Scripting
To address the first gap and Research Question 1, Simon and Gagnon’s (1984) Sexual Script Theory (SXS) will be used to guide this research. The origins of scripting behaviour began with Script Theory (1954) which was first conceptualised by phycologist Silvan Tompkins and has been used as a conceptual bases within the disciplines of psychology, services marketing, management and sexual health (Bateson, 2002; Bettman, 1986; Gagnon, 1990; Gioia & Poole, 1984; Grove, Fisk, John, Swartz, & Iacobucci, 2000; Ryan, 2011). Script Theory (1954) analyses human
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behaviour through an individual’s rules for predicting, interpreting, responding to, and controlling a set of scenes which are defined as an event with a perceived beginning and end (Tomkins, 1978). For scripted behaviour to occur three conditions need to be met (Abelson, 1981). The first is that the individual must have a stable cognitive understating of the script. This is usually formed from the cognitive retrieval from previous situations and behavioural outcomes and links directly to concept of the lived experience. The second condition is that the context for the script in which the behaviour is performed must be evoked and the third is that the individual must enter the script (Abelson, 1981).
The first applications of scripts to human sexuality was in 1973 when Gagnon and Simon noted parallels between the theater and scripted actions of actors and patterned behaviours of human sexual engagement (Gagnon & Simon, 1973; Wiederman, 2005). Building upon the work of Tompkins (1954) SXS proposes that people follow internalized scripts to construct meaning out of behaviour, emotion and interactions within a social context (Carpenter, 2010, Simon & Gagnon, 1984, 1986). Application of SXS gained traction in 1980’s with the need to understand contextual and social pressures of sexual behaviour in the wake of the aids epidemic. Since then the SXS perspective has remained robust and stable as an explanatory framework as it is responsive to historical and cultural changes (Simon & Gagnon, 1986; Štulhofer et al., 2010a; Wiederman, 2005). Table 4 outlines the application of SXS across different studies including, STI prevention, gender role, casual sexual relationships, homosexually and prostitution, pornography, and rape.
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Table 4. Applications of Sexual Scripting Theory
Context Focus Method Sample Reference High Risk N=207 (O’Sullivan, Hoffman, HIV Relationship attitudes, experience (103 Female, 104 Quantitative Harrison, & Dolezal, neighbourhood sand HIV risk behaviours male) 2006) New York Age 18–24 years African Interpersonal and sociocultural N=14 (Bowleg, Lucas, & American Qualitative Prevention influences on condom use Age 22-30 Tschann, 2004) Women
STI Social, cultural and gendered nature 28 Single sex focus Kenyan (Maticka‐Tyndale et al., of scripts for HIV prevention Qualitative groups Young people 2005) strategies Age 11-16 Applications to sex therapy- Male & preventative and therapeutic
Female sexual Conceptual n/a (Wiederman, 2005b) solutions to individual and couple roles sexual problems N= 33 Preschool Gender identification and recall from Qualitative (14 female, 19 male) (Levy & Boston, 1994) children narrative Age M= 4.5
Gender Gender Roles Influence of Lesbian mothers sexual Lesbian Mother n=27 (Golombok & Tasker, orientation on child’s sexuality. families Qualitative Children n=39 1996)
Sexual miscommunication & N=21 Young Adults understanding causal partners Qualitative (11 female &10 male) (Beres, 2010) willingness to have sex Age 19-30 Nonrelational sexual experiences; N=274 (Epstein, Calzo, Smiler, Young males Hooking up, and friends with Qualitative
Casual Casual (18-23) & Ward, 2009) benefits
Relationships College N=274 Social networks and “hooking up” Quantitative (Holman & Sillars, 2012) students Narrative of self-identified “bottoms” HIV Negative N=18 (person preferring receptive anal Qualitative (Hoppe, 2011) Men Age 27-66
intercourse)
Bareback (condom less) Race-based sexual stereotyping Qualitative N=111Age M= 35 (Wilson et al., 2009)
Sex
Racial and sex Preferred anal sex roles and Study 1 N=126 role Quantitative (Lick & Johnson, 2015) masculine identity. Age M=20
Homosexuality stereotypes Sexual positioning, decision making (Johns, Pingel, Young Gay N= 34 and gender role among young gay Qualitative Eisenberg, Santana, & men Age 18-24 men Bauermeister, 2012) Intimacy and control in escort Denmark N=36 (Järvinen & Henriksen, services, clinic prostitution & private Qualitative Sex industry (8 female, 8 male) 2018) apartment prostitution
Escorts & Intimacy, sexuality and pleasure in N=50 male massage Qualitative (Sanders, 2008) purchasing commercial sex Age 22-70 parlours N=650 (Štulhofer, Buško, & Young Males Pornography and sexual socialisation Quantitative Age 18-25 Landripet, 2010b) Use of internet pornography & sexual Female behaviour, attitudes toward women, N=168 college Quantitative (Maas & Dewey, 2018) endorsement of rape myths & body Age 18-29 students monitoring Rape & Seduction scripts- judgment College N=20 and variables. Qualitative Student (11female, 9 male) (Ryan, 1988, 2011) Rape Myths- men can’t stop, rapist Age M=18 are different from other men
Prostitution. Pornography Prostitution. & Pornography Rape Mixed N=50 University Rape attributes and unacknowledged methods; (42 female, 8 male) (Littleton & Axsom, students rape Qualitative N=130 2003) Quantitative (97 female, 33 male)
Literature Review 45
As seen in the Table 3 SXS has been effectively applied to diverse sexual, contexts to understand the complexity of cultural, personal, emotional and cognitive aspects of sexual behaviours. The primary focus of this work has been young high-risk ethnic communities, self-identification of gender and “deviant” behaviours. Condom use has been explored in third world countries and low socio-economic communities where HIV has become endemic. The following section will outline the constructs of SXS in detail and apply it to the context of this research.
2.11.1 Sexual Scripting of HMA Sexual Behaviours SXS has three dimensions that help understand and predict behaviour; cultural scenarios, interpersonal scripts and intrapsychic scripts (Simon & Gagnon, 1986). By understanding the intrapersonal, situational and socio-cultural contexts researchers are provided with an intrapsychic map of how people feel, think and behave within a situation (Simon & Gagnon, 1986; Wiederman, 2005). Application of these constructs to HMA prophylactic protective sexual behaviour is seen in Figure 9 and is followed by a discussion of each construct and how it applies to this research.
Figure 9. Sexual Scripting of HMA Sexual Behaviour
Script HMA Socurces Behaviour Type Script
Gender Role Cultural Sexual norms Uses a Historical Events Senarios Condom
Past Experiences Script Partner Type Interpersonal Interpretation Formation Does not Fantasies use a Intimacy Intrapsychic condom Arousal
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2.11.2 Cultural Scenarios The first script in SXS is cultural scenarios which incorporates factors such as gender role, societal norms around sex and sexuality and historical events. Cultural scenarios are the instructional guide that exists at the collective level and are communicated by members of the culture who have already adopted the script, mass media depictions of people acting and reacting in certain situations and social structurers and institutions (Simon & Gagnon, 1984; Wiederman, 2005). For HMA prophylactic protective sexual behaviour, cultural scenarios help explain the influence of gender role, sexual norms and historical events in casual sexual encounters. Wiederman (2005) proposes that couples rely on the gendered nature of the sexual script early on in relationships as an anxiety-reduction strategy to provide guidance for how the individual should act (Simon and Gagnon, 1984, Wiederman, 2005). Gender roles are learnt from an early age beginning with differing messages of genital contact. Male genitals are more easily accessible and are handled from an early age for urination, while females are taught to avoid contact with their clitoris and careful wipe to circumvent infection and transmission of bacteria from the rectum to the vagina (Wiederman, 2005). These anatomical differences are the initial stages of men being framed aggressors and women as gatekeepers in sexual activities. These roles continue into adulthood with males being praised for sexual conquest and use of their genitals and women labeled as deviant and at risk (pregnancy). With pregnancy no longer a risk to HMAs it is not known if the script changes and how this may impact prophylactic protective sexual behaviour. Both the role of aggressor and gatekeeper has the power to insist on condom use within the sexual encounter. Exploration of the lived casual sexual experiences of HMAs this research aims to understand how HMAs navigate condom use behaviour.
Gender roles also help form sexual norms around relationships and sexual activity. Traditional courtships learnt from previous generations, representation of relationships and sex in entertainment and the media and social structures such as marriage laws and vows specify the appropriate objects, aims, and desirable qualities of sexual interaction (Wiederman, 2005). It is also theses influences that have contributed to the stereotype of sexual decline and an ‘asexual’ old age. Exploration of the perceived societal sexual norms in comparison to those within HMA sexual encounters is part of understanding the lived experiences. Finally, historical events
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also play a part in forming the cultural scenario scripts of HMAs. As discussed in the literature review on sexuality and product development of the condom, HMAs have lived through considerable social and biological changes. The sexual revolution and free love of the 1960’s combined with the pill expanded contraceptive options beyond the condom for young HMAs (Blair, 2017). Many then settled down and got married conforming to cultural scripts and as a result may have missed prophylactic messaging around condom use and transmission of HIV/AIDS. Now in the later stage of their lives social norms arounds around marriage, divorce and separation have changed with HMAs finding themselves single and post reproductive (Brown & Lin, 2012). Despite cultural script changes to relationship structures norms around age and sexuality have remained the same (Carr, 2004).
2.11.3 Interpersonal Scripts The second script in SXS are interpersonal scripts which incorporate past experiences, partner type and negotiation skills. This script is the translation, interpretation and “acting out” of relevant cultural scenarios in sexual behaviours within particular contexts (Simon & Gagnon, 1984). In other words, interpersonal scripts help understand sexual behaviours between sexual partners within certain contexts. In regard to HMAs past experiences influence interpersonal scripts via the sexual patterns and behaviours developed over time and within casual sexual encounters. For example, if an HMA has never used a condom and cultural scenarios suggest that there is no personal risk as HIV is a “gay problem” then condom use is unlikely. These scripts also play out interpretations of gender role for example who should initiate the sexual activity, what is the appropriate response to sexual advances or types of sexual activities and who is responsible for proposing condom use. Partner type (casual or exclusive) can also influence interpersonal scripts as interpretation of perceived cleanliness and trust can influence to protective sexual behaviours (Hoffman & Cohen, 1999). Finally, interpretation plays a part in interpersonal scripts as HMAs have to interpret the relevant cultural scenarios, the context of the sexual encounter and their partner’s behaviour/script. For example, if both individuals in the sexual encounter have complementary scripts they know what to expect and how to behave resulting in minimal explicit communication and negotiation (Simon & Gagnon, 1984). Similarly, scripts that do not align can result in an awkward or unsatisfying
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sexual experience as communication to rectify these differences contradict cultural scenarios of spontaneous and romantic sex.
2.11.4 Intrapsychic scripts Finally, intrapsychic scripts are the internal motives behind the sexual activity and include fantasies, intimacy and arousal. These scripts are expressed through internal dialogue and management of desires that stem from the internal self (Simon & Gagnon, 1986). This script encapsulates why HMAs have sex and what they want out of the experience. When intrapsychic scripts do not match in a sexual couple there may be conflict and anxiety from the experience of sexual activity. There may also be irritation as the other person appears to be “not playing by the rules” and that everything would have worked if the followed the “normal” sexual script (Simon & Gagnon, 1986). Exploring the intrapsychic scripts of HMAs and how they are achieved through behaviours influenced by interpersonal scripts and cultural scenarios is vital to understanding the lived experience of HMAs and condom use behaviour.
2.11.5 Summary Sexual Scripting Theory Using SXS will provide a holistic and theoretically robust framework for eliciting and analysing of the lived sexual experiences of HMAs. SXS strategically aligns with the sexual health discipline and WHO operational framework (2017). It has been used to explore the determinants of condom use in high risk ethnic consumer markets however further understanding of the experience of using a condom is need. The strong emphasis on experiences requires the analysis of customer experience literature and how it applies to the context of HMA sexual experiences and prophylactic products. The following section will discuss the customer experience literature and the relevance to this research.
2.12 Customer Experience Literature
Customer Experience (CX) is a hot topic and a key marketing concept that is currently in its nascent stage. In 2015 key researchers within the field have stated that “Customer experience research remains fragmented with still relatively little known about the phenomenon” (McColl-Kennedy et al., 2015). Five years later echoes of this sentiment are still expressed by scholars with Becker & Jaakkola (2020) stating that while there have been a number of studies on CX there is still considerable fragmentation and theoretical confusion. This reaffirms that we are in the experience
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age of research and that the exploration of fulfillment transcends disciplines. A social marketing and sexual health perspective on the CX of HMA prophylactic protective sexual behaviour means viewing the mature adult as a customer. The engagement in sexual behaviours is termed the customer experience and this includes sexual activity both with and without a condom.
2.12.1 Roots of Customer Experience Emerging from the marketing and management disciplines the roots of CX literature started with the holistic notion of CX creation and the importance of experiences in consumer behaviour (Holbrook & Hirschman, 1982). Table 5 chronologically summaries the roots of CX literature up to the seminal article by Pine and Gilmore in 1999 and is followed by a discussion of the evolution in the field.
Table 5. Roots of Customer Experience Literature 1982-1998
Year Author(s) Discipline Method Context Dimensions/ Focus Holbrook Consumption 1982 & Marketing Conceptual Symbolic, hedonic and esthetic Experiences Hirschman Thompson, Existential-phenomenology 1989 Locander Marketing Conceptual Consumption paradigm & Pollio Physical surroundings, employee Mixed 1990 Bitner Marketing Travel Agency response & attributions Methods
Hui & Consumer choice & consumer 1991 Marketing Experimental Bank & Bar Bateson density Ambiance, spatial layout and Consumers & functionality, sings symbols and 1992 Bitner Marketing Conceptual Employees artefacts
Expectations, performance, affect, Arnould & Mix 1993 Marketing River Rafting narrative & ritual Price Methods
Design principles, control, Carbone & experience clues mechanics and 1994 Business Conceptual Design Haeckel humanics & integrated processes
Speed, convenience, responsiveness, choice, lifestyle, discounting, value 1994 Rowley Management Case study Libraries adding, customer service, technology & quality Hedonic, piece of mind, Otto & Airlines, hotels & 1996 Tourism Quantitative involvement & recognition Ritchie tours
Tourism, call Dawes & centres, expert Inseparability, Variability, 1998 Management Case studies Rowley systems & Perishability & Intangibility internet shopping
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As seen in Table 4 preliminary studies of CX focused on the conceptual development of CX and how to address manageable features (service environments, employee response, expectations and consumer choice) of a single service encounter. With an understanding of CX concepts research began to focus on trying to mitigate the effects of negative service experiences within a firms control (Bitner, 1990). The direction of CX research then moved from reactive to proactive control of the service encounter environment and things deemed beyond the control of the firm or service provider (Hui & Bateson, 1991). This lead to managing CE and creating servicescapes with investigations on how physical surroundings, atmosphere, spatial layout, functionality of a store, signs, symbols and artifacts create an experience (Bitner, 1992). Experiential concepts were then applied to different contexts primarily the hospitality and tourism industries. This saw the expansion of CX through the study of complex and prolonged experiences (Arnould & Price, 1993). This was a change from short term purchase and evaluation concepts from consumer behaviour theories that have been previously studied.
2.12.2 Defining Customer Experience: Managerial Stimuli & Consumption Processes The seminal article on customer experience was by Pine and Gilmore (1999) who conceptualised the experience economy, entertainment educational, esthetic and escapist. It is proposed that experiences can be understood by using these four realms which are based on the intersection of consumer participation and immersion (Pine & Gilmore, 1999). It is believed that the richest experiences encompass all aspects of the four realms (entertainment educational, esthetic and escapist) with the “sweet spot” occurring at the intersection of consumer participation and immersion (Pine & Gilmore, 1999). After the development of the experience economy, marketing, management, tourism and design disciplines explored the concepts of CX and its application across different contexts and types of experiences. As previously stated CX research still remains fragmented with relatively little known about the phenomenon (McColl-Kennedy et al., 2015). Exploration of the CX literature identified two overarching classifications: managerial stimuli and consumption processes (Becker & Jaakkola, 2020). Literature that focuses on the managerial stimuli views CX from the role of the firm and how they define, design, monitor and respond (Table 6). Literature that focuses on consumption processes concentrates on the
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consumer and their views on CX offerings, responses to CX stimuli and evaluation of CX outcomes (Table 7).
Table 6. Customer Experience and the Role of the Firm Literature
Dimensions/ Focus Context Discipline Method Author(s)
Sensory experiences (sense), affective experiences (feel), creative cognitive Experience Schmitt (1999) experiences (think), physical experiences Marketing Conceptual providers behaviours & lifestyles (act) & reference
group or culture (act) Lifting up experiences, reciprocating Mobile Battarbee and experiences, rejecting & ignoring multimedia Design Qualitative Koskinen experiences. usage (2005) Promotion, price, merchandise, supply Grewal, Levy, Retail Marketing Conceptual and Kumar chain and location (2009) Typology of Cultural mindsets, strategic directions, and CX Homburg, firm capabilities for continually renewing Marketing Conceptual Jozić, and management CX Kuehnl (2017) Defining Firm Offering Defining Offering Firm patterns Temporal & Kranzbühler, Systematic & dynamic sequenced touch theoretical Kleijnen, Management Management Morgan, and points development Teerling of CX (2018) Ambiance, spatial layout and functionality, Airport Rowley and Marketing Qualitative sings symbols and artefacts lounges Slack (1999) Personnel, service elements, selection, price, design, display, layout, atmospherics, Retail instore Bäckström and Qualitative Business Johansson social aspects, tasks, purchase, time and experience (2006) mood
Offering Speed, convenience, responsiveness, choice, Case study & lifestyle, discounting, value adding, Museums Hospitality experience Rowley (1999) customer service, technology & quality audit Physical environment, human interaction, Hotels Quantitative Hospitality Walls (2013)
Designing emotive value & cognitive value Social environment, service interface, retail Verhoef et al. atmosphere, assortment, price, alternative Retail Conceptual Marketing (2009b) channels & brand Emergency Experience clues- mechanics and humanics, Experience Berry et al. rooms & car Management senses and environment Audit (2002) rental Servicescape, feelings, satisfaction, brand Services Grace and Banking Quantitative
attitudes Marketing O'Cass (2004)
Speed, importance, focused attention, Novak, skill/control, challenge/arousal, Online Quantitative Hoffman, and Marketing telepresence/time distortion, flow, & environments Duhachek exploratory behaviour (2003) Personnel, service elements, selection,
Monitoring Retail and Battarbee and
& Responding & Responding price, design, display, layout, atmospherics, customer Qualitative Business Koskinen social aspects, tasks, purchase, time and views (2005) mood Beauty salon Wu, Yeh, and Service facets, intentions, service outcomes and Spa Quantitative Management Woodside treatments (2014)
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Table 7. Customer Experience and Responses to Consumption Literature
Dimensions/ Focus Context Discipline Method Reference
Business & Pine and Gilmore Entertainment, education, esthetic & escapist retail service Economics Conceptual (1999) experiences Knowledge is the fundamental source of competitive advantage, All economies are Service services economies, Customer as coproducers, Service dominate Conceptual Enterprise can only make value propositions, marketing Vargo and Lusch logic Service-centred view is customer oriented and (2004) relational. Relationship, personal involvement, trust, Addis and Consumption Marketing Conceptual utilitarian and hedonic. Holbrook (2001) Customer touchpoints, relationship lifecycle TNT express Frow and Payne and market segment services & Marketing Conceptual (2007) Guinness Touchpoints, Value creation (resources, McColl-Kennedy, Business to Zaki, Lemon, activities, context interaction, customer role), Marketing Conceptual Discrete emotions & Cognitive response business Urmetzer, and Offering related Offering CX stimuli related Neely (2019) Consumer experience, extraordinary Ordinary experience, consumption experience and Marketing Conceptual Carù and Cova experiences ordinary experience (2003) Customer value co-creation practice style McColl-Kennedy, typologies; team management, insular Healthcare Vargo, Dagger, Marketing Qualitative controlling, partnering, pragmatic adapting & Customers Sweeney, and passive compliance Kasteren (2012) Broadening customer role, practice-based Role of Services McColl-Kennedy Conceptual approach, holistic nature Customer marketing et al. (2015) Sensorial, emotional, cognitive, pragmatic, Role of
lifestyle, relational different Mixed Gentile, Spiller & Marketing experiential methods Noci (2007) features
Stimuli Stimuli Atmospheric, technological, communicative, process, employee–customer interaction, Retail Qualitative Stein and CX CX Marketing Ramaseshan customer–customer interaction and product experience (2016) interaction elements. onse toonse Situations and determinates of CX- Hedonic, Co-creation Jaakkola, cognitive, social, personal, pragmatic, from the Services Mixed Helkkula,
Resp Aarikka-Stenroos, economic. customer Marketing Methods and Verleye perspective (2015) Customer perceived value and service I phone initial Services Helkkula and Qualitative experience launch marketing Kelleher (2010) Multiple project enablers (expertise diversity), project principles (stakeholder involvement), Mahr, Kalogeras, Healthy food Services project challenges (shared team understanding) Quantitative and Odekerken‐ interventions marketing & project outcomes (hedonic and functional Schröder (2013)
benefits) Evaluating CX
Outcomes Co -creation motive, Co -creation on form, Managing co- Frow, Nenonen, Engaging actor, Engagement platform Level of creation Management Conceptual Payne, and engagement, Duration of engagement design Storbacka (2015) Touch points, key drivers, partners, networks, Customer Lemon and Marketing Conceptual internal firm perspective. Journey Verhoef (2016)
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As seen in Tables 6 and 7, the conceptual development of CX constructs and mechanisms are still being proposed today, two decades on from Pine and Gilmore’s (1999) seminal article (Becker & Jaakkola, 2020). In an effort to define and understand CX scholars have explored experiential elements of products and services across a variety of offerings, user interaction and co-experiences between groups (Battarbee & Koskinen, 2005; Becker & Jaakkola, 2020; Berry et al., 2002; Frow & Payne, 2007; McColl-Kennedy et al., 2015; Schmitt, 1999). This body of work primarily focused on the CX between the firm (provider) and consumer/ group of consumers. Ultimately CX has been portrayed in the literature as elements that can be created or spontaneously occur to which a consumer interacts or reacts to positively or negatively. These interactions do not take into consideration the consumers lived experiences and the implications of cognitive recall on the consumers interpretation of CX stimuli and anticipated experiential outcome. This sentiment was echoed by
Helkkula and Kelleher (2010) who found as an implication form their research on customer service experiences and perceived value, that it is impossible to understand the customer experience in isolation from their other “lived experiences” within their phenomenological frame of reference (Helkkula & Kelleher, 2010). This explicitly links the lived experience in the sexual health literature, the experience age and this research (Van Manen, 2016).
2.12.3 Customer Experience in the Experience Age of Sexual Health The experience age of sexual health focuses on the formation of psychosocial scripts and how lived experiences of mature adults help them navigate protective sexual behaviours. Translating this to a social marketing and customer experience lens positions mature adults as consumers. This looks beyond the social determinants of behaviour to the specific product/service element that can create value and facilitate behaviour. The culmination of CX research has elicited two key theoretical concepts that pertain to this research; service dominant (S-D) logic and the co-creation of value. As previously stated in Section 2.3.1, services are the fundamental basis of exchange (Vargo & Lusch, 2004, 2008; Vargo et al., 2008). This is because a service is considered to be both operant resources (knowledge and skills) and the value derived using durable and non-durable goods (Vargo et al., 2008). In context of this research the “service” of HMA prophylactic protective sexual behaviour is an individual’s knowledge (the theoretical and practical understanding) and skills (the ability to use)
54 Literature Review
a condom, the value derived from use and traditional sexual health services; GP, STI clinics, education and counselling. CX originates from a set of interactions between a customer and a product, company or part of an organisation that in turn creates value (Addis & Holbrook, 2001; Helkkula & Kelleher, 2010). Thus, the second concept, co- creation of value is intrinsically entwined in S-D logic, social marketing, sexual health and the experience age of research. This research takes the approach of Grönroos & Voima (2013) and by extension McColl-Kennedy et al (2015) and McGraw, Russell- Bennett & White (2018) in viewing co-creation of value as an active function of interaction and fundamental to understanding CX (Grönroos & Voima, 2013). Prophylactic protective sexual behaviour is a complex experience as it involves the active participation of two people with the product and offering.
Gap 2. We do not know the lived customer experience elements of condom use by heterosexual mature consumers.
2.13 Theoretical Framework 2- Six Component Customer Experience Framework
The second gap and Research Question 2 (RQ2) will use Gentile, Spiller & Noci’s (2007) six component customer experience framework (CXF); sensorial, emotional, relational, cognitive, pragmatic, lifestyle. As seen in table 2.3 and 2.4 the operational constructs of CX is still being debated and conceptualized. Thus, there are limited studies that state Gentile, Spiller & Noci’s (2007) CXF as the guiding theory. When evaluating the potential frameworks for this research CXF was found to be the most conceptually robust. Similar application of CXF to health topics have included breast feeding and breast augmentation expectations (Brady, 2019). The following section will discuss the elements of CXF and how they apply to the context of this research.
2.13.1 Customer Experience of HMA Sexual Behaviours Gentile et al (2007) propose that good experiences involve a person across multiple dimensions and while the experience may be perceived as complex it is viewed holistically (Gentile et al., 2007). The framework (Figure 2.8) builds upon value creation and co-creation theories where there is an exchanged value between the company and consumer. This value is classified as either utilitarian value (or functional value) and hedonic value (or experiential value). In the context of HMA
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prophylactic protective sexual behaviour use of a condom has utilitarian value through the protection from diseases and may create or inhibit the hedonic value though its use. Gentile et al.’s CXF (2007) reflects the complex nature of sexual behaviour and acknowledges the integration of sensation, cognition and affect and how values, beliefs and relationships influence behaviour. The holistic perceptive and focus on exchange aligns with both the social marketing and sexual health lens. Following Figure 2.8 each of the elements for CXF will be discussed in detail and applied to the context of this research.
Figure 10. Customer Experience Framework
Sensorial The sensorial component of HMA prophylactic protective sexual behaviour involves sexual experiences that stimulates the senses (sight, sound, touch, taste & smell) to arouse aesthetical pleasure, excitement, satisfaction or sense of beauty (Gentile et al., 2007). This component helps explore how prophylactic protective sexual behaviour impacts the physical sensations, biological functioning and evaluation of the experience. This research will explore both male and female participants lived sensorial experiences of condom use. It will also explore participants
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perceptions of their partners sensorial experience and perceptions of the shared experience.
Emotional The emotional component of HMA prophylactic protective sexual behaviour comprises of the affective system through the generation of moods, feelings and emotion created from the experience (Gentile et al., 2007). This component helps understand the feeling and emotions that are associated with sexual activities both with and without a condom. This element also explores emotions towards the prophylactic protective sexual behaviour, the product (condom), sexual partner and oneself.
Relational The relational component of HMA prophylactic protective sexual behaviour include sexual experiences that encourages consumption with others and encompasses the customer, their social context, relationships and ideal self (Gentile et al., 2007). This component relates to the type of sexual relationship that the HMA couple are engaging in. This reflects the social context of the sexual relationship (hooking up, casual sex, fuck buddies, friend with benefits, boyfriend/girlfriend/partner, exclusive) and what the participant wants out of the relationship and perceptions of what they think their partner relationally wants out of the sexual experience.
Cognitive The cognitive component of HMA prophylactic protective sexual behaviour is connected with thinking or conscious mental processes that engage consumer problem solving and creativity (Gentile et al., 2007). This component reflects the perceived risk and susceptibility to STIs and the need to use a condom. This also includes strategies and creative processes such as negotiation and eroticising the product to encourage condom use. This is a result of the product being shared within the experience and both participants need to consent to and facilitate its use. Therefore, the creative cognitive element of CXF is most likely engaged when one partner wants to use a condom and the other does not.
Pragmatic The pragmatic component of HMA prophylactic protective sexual behaviour involves sexual experiences that comprise of the practical act of doing something and or the concepts of usability (Gentile et al., 2007). This component looks at the tangible
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features of a condom from the products use, packaging, application, use and disposal. For HMAs physiological changes associated with aging such as sexual dysfunction, diminished dexterity of hands and impaired eyesight may impact product usage. It also includes the intangible pragmatic features of use including the purchase, transportation, discussion and negotiation around use.
Lifestyle The lifestyle component of HM(French & Blair-Stevens, 2006)A casual sexual encounters involves sexual experiences based on the affirmation of consumer’s values and beliefs created through the adoption of lifestyle and or behaviours (Gentile et al., 2007). This component helps understand the current dating lifestyle of HMAs and how values and beliefs are formed form past relationships, sexual norms and historical events. The affirmation of these values and beliefs within the sexual relationship may impact further HMA condom use behaviour.
2.13.2 Summary Customer Experience Literature Using CXF will provide a strategic and innovative framework for eliciting and analysing the lived sexual experiences of HMAs. CXF strategically aligns with the social marketing discipline providing constructs to define and explore the social offering of prophylactic condom use (Dann, 2010b; French & Blair-Stevens, 2006). It will enable the exploration of the customer experience of both the individual HMA and the shared customer experience of using a single product.
2.14 Chapter Summary
In summary, prophylactic protective sexual behaviour by heterosexual mature adults has received limited attention in the sexual health literature. However, ideologies and concepts form the sex and sexuality research combined with the product development and positioning of condom use gives insight of potential factors influencing HMA behaviour. The lived experience of HMAs needs to be explored to understand how cultural and societal pressures combined with interpersonal and intrapsychic motivations of sex help HMAs navigate protective sexual behaviours. The complexity and duality of the customer experience of the behaviour and a shared product (condom) also need to be explored. Chapter 3 will discuss the methodology used by this research to explore the key concepts and gaps in the literature that have been discussed in this chapter.
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Chapter 3: Research Design
Chapter 2 established that there is need for further research on the lived sexual experiences of HMAs and the customer experience (individual and shared) of prophylactic protective sexual behaviours. The conceptual evolution of sex and sexuality research and the condom was discussed illustrating the variations in societal norms around sexuality and the duality of the product. The current literature on HMA Sex and Sexuality, quality of life, health communication and customer experience were also discussed. This chapter will outline the philosophical approach taken by this study and the qualitative research design. The method of data collection, analysis and ethical considerations will then be discussed.
This study utilised a qualitative research design with the underlying philosophical assumptions in line with a constructivism, subjectivist approach (Denzin & Lincoln, 2011). Semi-structured interviews and the use of projective techniques in the form of psycho-drawings provided the opportunity to explore the complex nature of sexual experiences and protective sexual behaviours (Boddy, 2005). The interviews were cross sectional and conducted either on campus at QUT or via telephone. Purposeful criterion-based sampling was used to find sexually active, heterosexual participants who were aged 50 years or older and not in a committed relationship (Miles & Huberman, 1994). Data collected was analysed using an inductive- deductive approach and was contextualised by the individual and their personal sexual experiences with and without condoms (Fereday & Muir-Cochrane, 2006).
3.1 Philosophical Approach
The complexity of sexual relationships and behaviours requires a philosophical approach that looks beyond the individual to the couple and context in which the sexual activity occurs. Consequently, a subjective approach was taken with the core ontological assumption positioning reality as a social construction (Denzin & Lincoln, 2011). As seen in Table 8 the constructivism paradigms ontology proposes that social reality is a continuous and adaptive process whereby individuals establish meaning, definition and symbolic attitudes of the world. These symbolic attitudes aim to make the world more intelligible and are developed through the use of language, labels,
Research Design 59
actions and routine construction (Denzin & Lincoln, 2011). It also proposes that individuals may work together to create a shared reality as a result of conscious and involuntary knowledge. This ontology was chosen as it takes into consideration the evolution of older adult’s social realities from their distinctive life histories and provides insight into the construction of shared realities such as sexual relationships.
Table 8. Research Paradigms
Positivism Post positivism Critical Theory Constructivism
Historical realism-
Critical realism- virtual reality shaped Relativism- local and Naïve realism – “real “real” reality but only by social, political, specific constructed reality but imperfectly and cultural, economic, and co-constructed apprehendible probabilistically ethnic, and gender Ontology realities apprehendible values, crystallised over time.
Modified dualist/objectivist; Transactional/ Transactional/ Dualist/objectivist; critical subjectivist; value- subjectivist; created findings true tradition/community; mediated findings findings findings probably
Epistemology true
Modified experimental/ Experimental/ manipulative; critical manipulative; multiplism; Hermeneutical/ verification of Dialogical/dialectical falsification of dialectical
Method hypotheses; chiefly hypotheses; may quantitative methods include qualitative methods
Critique and Explanation: Explanation: Transformation; Understanding; Prediction and Prediction and
restitution and reconstruction Aim of inquiry control control emancipation
Adapted from Denzin and Lincoln (2011)
The epistemology of this study reflects a social constructivist perspective whereby social reality is constructed thorough subjective and consensual meanings (Denzin & Lincoln, 2011). This perspective focuses on understanding the construction of knowledge and local truths within a specific culture and or context (Derry, 1999; McMahon, 1997). This understanding of “local truths” is vital to the exploration of mature adult sexual decision making as their distinctive life history has resulted in differing motives, experiences and values that have been construed over time.
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Symbolic Interactionism (Blumer, 1969) has been selected as the research methodology as it has tremendous potential to increase the understanding of human health behaviours (Benzies & Allen, 2001). This method has three simple premises. Firstly, humans act toward things based on the meanings they ascribe to those things (Blumer, 1986). Secondly meanings arise out of the social interaction that one has with other individuals and society. Thirdly, people can form new meanings and new ways to respond through the process of interpretation (Blumer, 1986). To summarise symbolic interactionism provides a theoretical perspective for studying how individuals interpret objects and other people in their lives and how this process of interpretation leads to behaviour in specific situations (Benzies & Allen, 2001; Blumer, 1986).
In the context of this study symbolic interactionism helps to answer the research question by exploring the symbolic meaning of the “object” condoms and how this influences sexual behaviours. It takes into considerations the meaning, values and emotions attached to condoms by the individual. How these meanings are communicated in a sexual relationship and finally how they can change dependent on the context of the relationship and or partner.
3.2 Qualitative Research Methods
According to Creswell (2013) qualitative research is necessary when an issue or problem needs to be explored. This is especially true when the issue is complex and detailed understanding is needed of a specific population, identifiable variables that cannot be easily measure and or silenced voices (Malhotra, 2006). There are multiple methods for collecting qualitative data each with their own advantages and disadvantages. These methods were assessed along with their use sensitive topics to find the most appropriate method for this study. Table 9 outlines potential qualitative research methods, the advantages and disadvantages and application to sensitive topics and suitability to this research. The chosen method (interviews) is highlighted and following the table dissuasion of the chosen method is presented and justified.
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Table 9. Qualitative Data Collection Methods and Suitability to this Research Observation Ethnogeny Netnography Focus Groups Interviews A systematic data Systematic study of Research practices Moderated group A conversation collection approach people and cultures where a significant discussion where questions are
where the where the researcher amount of the data organised to explore asked to elicit researchers use all observes society collected originates a specific set of information to their senses to from the point of in and manifests issues. uncover the examine people in view of the subject through the data meanings of central
natural settings or of the study. snared freely on the themes in the world Definition Definition naturally occurring Internet. of the subject from situations. their own point of view. +Richly detailed Enables a + Unobtrusive +Able to explore + Rich & description relationship to + Participants may personal and group descriptive data +Opportunities for develop with be more open online feelings, + Flexible and
viewing or research participants + Rich descriptions perceptions and responsive method participating in over the period of and intricate detail opinions (semi/unstructured unscheduled events study + Naturalistic, set in + Provide a broader only) +Behaviours, Naturalistic, set in the subject’s world range of + Familiar to intentions, the subject’s world +Easy to obtain data information participants Advantages situations, and Captures behaviour +Opportunity to + Ability to follow events are as and emotion in the seek clarification up understood by one's different contexts of informants everyday life -Time consuming -Extensive training -Ethics are complex, -Convenience -Bias & subjectivity -Observer bias/risk -Cost rapidly changing recruiting -Generalisation of getting too -Time consuming - Trustworthiness of -Hard to control and problem involved (build trust) online identity and manage -Time consuming -Representatives -Culture shock communication -Group may be -Small sample size (small sample size) -Active members dominated by - Participants do not get more focus opinionated
Disadvantage always act naturally members -Moderator bias -Cost
-Domestic violence -Homosexuality -Cosmetic surgery -Sexual violence -Sexual behaviours -Drug addicts - Relationships -Postpartum -Suicide -Domestic violence -Prostitution -Cheating psychosis -Death & -Mental illness -Menstruation -Anorexia Bereavement -Death -Menstruation & menopause
-Mature adult Sensitive Topics Sensitive
behaviour
NOT SUTABLE NOT SUTIABLE NOT SUTALBE NOT SUTIABLE SUTIABLE Inappropriate to Unable to become Inadequate presence Nature of group Provides the best observe sexual “part of the of online discussion would environment for
behaviour. community”. community. inhibit some building rapport and ability Inappropriate and participants & not discussion of
Suit unethical. allow full sensitive topics. exploration of topic. (Denzin & Lincoln, 2011; Krefting, 1991; Lee & Renzetti, 1990; Mallon & Elliott, 2019; Marshall & Rossman, 2011; Smith, 2015; Van Manen, 2016; Watts & Stenner, 2012)
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3.3 Interviews
Interviews were deemed as the most appropriate method for this study as they facilitate “thick description” from multiple participants in their own words (Denzin & Lincoln, 2011). Interviews are familiar to participants and can be structured, semi structured and unstructured (Patton, 2015). This research selected a semi structured approach as it allows freedom for the interviewer to adjust language and use scheduled and unscheduled probs to uncover a version of the truth through the eyes of the participants (Fylan, 2005; Malhotra, Hall, Shaw, & Oppenheim, 2006). The major limitation of the semi-structured interview approach is the risk that important and salient topics may be inadvertently omitted (Patton, 1999). This is especially true for sensitive topics. This research explores not only a sensitive and private behaviour in a population where the behaviour is deemed socially unacceptable. To overcome this issue projective techniques were also utilised and discussed further in section 3.4. Semi structured interviews are also time consuming, have small sample sizes and thus have issues with generalisation due to bias and subjectivity (Denzin & Lincoln, 2011; Krefting, 1991; Marshall & Rossman, 2011; Smith, 2015; Watts & Stenner, 2012). However as seen in table 3.2 observations, ethnography, netnography and focus groups are all deemed inappropriate for the context of this research due to the private and sensitive nature of the topic.
3.4 Projective Techniques
Projective techniques were first employed in market research in the 1940s to help research participants express feelings and attitudes that might otherwise be withheld due to embarrassment or fear (Catterall & Ibbotson, 2000). Also used in clinical psychology a projective technique involves presenting the participant with a stimulus that does not make sense and asking them to make sense of it. In order to do so the participant will have to fill in the picture and add information and in doing so project part of themselves into the stimulus (Haire, 1950). Sensitive topics have the potential to cause harm to participants and/or researchers as they are generally considered to be private and can elicit strong negative emotional responses such as anger, sadness embarrassment, fear and anxiety (Elmir, Schmied, Jackson, & Wilkes, 2011), projective techniques enable the exploitations of sensitive thoughts and feeling in a painless unobtrusive way and elicit motivational pattern that the participant may not be willing or unable to otherwise express.
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Projective techniques can generally be classified in terms of the mode of response and can be grouped into one of five categories; association, construction, completion, choice ordering and expressive (Lindzey, 1959). Table 10 outlines the five categories and highlights the chosen technique for this research. Following the table justification is provided before moving onto the sampling procedure.
Table 10. Projective Techniques Classifications and Activities
Explanation Goal Activities Association techniques require the subject Vocabulary Word association, Ink to respond to the presentation of a blots (Rorschach Test) Association stimulus with the first thing or things that come to mind. Construction techniques require the Feelings, Bubble drawings, participant to construct a story around a attitudes, projective questions Construction fairly vague or ambiguous picture actions & Thematic apperception opinions test (TAT) Completion techniques require the Feelings & Incomplete Stories, participant to complete sentences or attitudes brand mapping, comic Completion stories which can stimulate differing ideas stirps and feelings. Choice Choice ordering techniques require the Importance Pictures, sentences, participant to rearrange pictures or chose &comparisons statements Ordering the order of preferences. Expressive techniques require the Role adoption Drawing, painting, Expressive participant to express themselves though psychodrama and selected mediums. puppetry (Boddy, 2010; Francis-Williams, 2014; Lindzey, 1959; Will, Eadie, & MacAskill, 1996).
Construction projective techniques were selected for this research as the technique allows people to respond freely as they do not explicitly state how they personally act, believe or think (Will et al., 1996). Despite this the responses given usually mirror the participants own feelings, attitudes, actions & opinions (Gordon and Langmaid, 1988). The sensitive nature of sexual behaviour may cause participants to unknowing engage in response bias where as they tell the researcher what that they think they want to hear or what is considered socially desirable (Furnham, 1986). The use of constructive projective techniques distances the participant form the projective question and allows them to express an opinion which they might fear to be unusual or atypical. Construction techniques also aim to elect participants actions and as prophylactic protective sexual behaviour requires action form both sexual partners it was important that this action was captured in the data. A bubble drawing activity was chosen to capture this information and is discussed in section 3.6 interview design. It should also be noted that this technique also aligns with the constructivist research paradigm (Denzin & Lincoln, 2011).
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3.5 Sampling Strategy
According to Miles and Huberman (1994) there are 16 typologies of sampling strategies in qualitative inquiry; maximum variation, homogenous, critical case, theory based, confirming and disconfirming cases, snowball, extreme or deviant cases, intensity, politically important, random purposeful, stratified purposeful, criterion, opportunistic, mixed or convenience. This study utilised a purposeful criterion-based sampling strategy to ensure both the quality of the data and true rich description (Miles, 1994). The use of this sampling strategy ensured that those who participated in the study have been involved in the central phenomenon of creating meaning from sexual experience and behaviours (Marshall & Rossman, 2011). Participants had to meet four conditions in line with the purposeful criterion sampling typology (Miles, 1994). The inclusion criteria were to be aged 50 years or older, identify as heterosexual, not be in a committed relationship and be sexually active.
The sample was exceedingly difficult to recruit due to the sensitive nature of the topic, ageist altitudes towards mature adult’s sexuality and the required inclusion criteria. As a result, three methods of recruitment were utilised: word or mouth, a media release and Q&A market research panel. While there was much interest generated from the media release the majority of those who reached out did not meet the inclusion criteria and could not be included. The media release and screener used by Q&A market research panel are provided in Appendix D and Appendix E. The combined efforts resulted in a final sample size of 24 heterosexual mature adults (N=24). The sample was gender balanced with 12 males and 12 females aged between 50-70 years old at the time of the interview. Participants were located on the east coast of Australia with 19 participants from Queensland (10 males and 9 females), 3 from New South Wales (1 male and 2 females) and 1 male from Tasmanian and 1 female form Victoria. Ideally participants aged 70-90+ years were also desired for this research; however, they proved to be too hard to attain. The final sample size (n=24) was deemed theoretically appropriate for both the qualitative method and context of the research (Marshall & Rossman, 2011; Mason, 2002; Robinson, 2014). The following section will discuss the interview design and process for data collection.
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3.6 Interview Design
Once participants were screened and voluntarily agreed to participate a time for the interview was scheduled and they were sent a QUT Participant Information Form and QUT Consent Form (Appendix F). Interviews within Queensland were conducted on campus at QUT Gardens Point in a private room. The interview in Tasmania was conducted in a private room at the Hobart public library. Upon arrival to the interview participants also received a hard copy of the forms for signing. The remaining interviews were conducted via telephone and signed consent forms were received via fax or email before the interview took place. The interviews followed the approved semi-structured interview guide (Appendix G) the two stages are discussed in the following sections.
3.6.1 Stage 1 Demographics and Semi Structured Interview The first stage of the interview was used to collect demographic data and gain a greater understanding of the lived sexual experiences of participants. While the participant filled out the consent and demographic forms the interviewer answered any questions raised and engaged the participant in casual conversation about their day and interest in the research to build rapport. Building rapport is considered to be the foundation of effective interaction and as the research topic is both sensitive and private in nature it was vital that participant felt conformable with the interviewer (Abbe & Brandon, 2013; Clarke, 2006). After receiving both written and verbal consent to record the interview the process was explained, and the first semi structured questions were asked, these included; What are your opinions on condoms, Have you ever used them? and Who is/was the main influencer in your decision to use or not use a condom? These questions lead to discussions about their lived sexual histories, sexual behaviours, historical events, sexual health communication and education, relationships, marriage, children and what it is like to date as a mature adult. This discussion links directly to RQ1 and elicited elements that help explain how the participant navigates sexual behaviour contextualised by their lived experiences. Once participants’ sexual history, attitudes and practise of protective sexual behaviours had been explored, the second stage of the interview was conducted using the projective technique.
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3.6.2 Stage 2 Projective Techniques: Bubble Drawings
The second stage of the interview required participants to fill out two bubble drawings. Bubble drawings are where the respondent is given a stimulus and are instructed to fill in the bubbles for the corresponding characters (Donoghue, 2000). It is hypothesised that the responses will reflect the participants own attitudes, feelings and behaviours (Donoghue, 2000; Will et al., 1996). To address RQ2 participants were given two bubble drawings on A3 paper depicting two different scenarios (Figure 11 and Figure 12). As seen in the figures the bubble drawing depicts a male and female couple one with a condom and one without. The participants were asked to imagine that the couple are going to have sex and to fill in what they think each person is thinking, feeling and their expectations from engaging in the behaviour.
Figure 11. Bubble drawing without a condom
Figure 12. Bubble drawing with a condom
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Participants were able to choose which of the drawings they wanted to complete first. The majority of participants picked the scene without the condom as they stated that this was the more common scenario for them. To help articulate their emotions participants were also provided with emotion stickers for each bubble person based on the hierarchy of consumer emotions (Laros & Steenkamp, 2005). A list of these stickers is provided in Appendix G. Once the scenario seen was set participants stuck stickers, wrote comments and even contextualised the couple adding ages, how many dates they had been on and for the bubble drawing with a condom who was responsible for bringing it. While most participants enjoyed the activity, some participants found that the activity was beyond their ability and or too confronting to put on paper. In this case the interviewer offered to fill it in for them. If this was still not enough further exploration of the participants oral history was conducted and questions about what they think, feel and expect out of their sexual relationships were discussed. Participants who were interviewed over the phone were sent an email with the bubble drawing and emotions and were taken through the activity. At the end of the bubble drawings participants were asked if there was anything else they would like to add or comment on. Following this they were debriefed, thanked for their time and compensated with a Coles Myer gift card. Participates recruited via word of mouth or the media release were compensated for their time with a $AUD30 and those recruited by Q&A received a $AUD70 in line with their recruitment policy.
3.7 Data analysis
The data analysis began with the transcription of the audio files where participants were deidentified and assigned a code name to ensure anonymity. The interviews were transcribed into NVivo software package where they were read and reread by the interviewer to form pattern recognition (Rice & Ezzy, 1999). An inductive deductive approach as described by Fereday and Muir-Cochrane (2006) was used to identify overarching themes within the data. Figure 13 outlines the inductive deductive approach taken by this research to ensure transparency in the coding process and rigour of analysis.
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Figure 13. Data Analysis Process
Stage 1 • Develop code book
Stage 2 • Test reliability of codes
Stage 3 • Summarise data and identifying themes
Stage 4 • Apply code template and additional codes
Stage 5 • Connect the codes and identifying themes
Stage 6 • Corroborate & legitimise coded themes
Adapted from Fereday and Muir-Cochrane (2006)
The first stage was to develop a code book from the research questions and theoretical frameworks SXS and CXF (Braun & Clarke, 2012; Fereday & Muir- Cochrane, 2006; Gentile et al., 2007; Simon & Gagnon, 1984). This codebook has been provided in Appendix H. Stage two tested the reliability of the codes by evaluating them against the raw data (Marshall & Rossman, 2011). Comparisons were then made between the codes, understanding of the data and literature under guidance from the supervisory team (Fereday & Muir-Cochrane, 2006). Moving onto stage three each piece of data (transcripts and bubble drawings) were summarised and initial themes were identified. This step also naturally occurred during transcription and pattern recognition from reading and rereading the data (Rice & Ezzy, 1999). In stage four the codes and identified themes were connected and new themes not articulated in the code book were discovered and clustered into categories and broader themes. Stage five was where codes and themes were connected to find points of intersection and relationships that may be causal (Marshall & Rossman, 2011). In the final stage codes were verified and confirmed to ensure validity, credibility, and trustworthiness. As seen in figure 3.3 this was an iterative process that was closely examined to ensure that the developed themes were representative of the data and theoretical and data driven codes.
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3.8 Ethical clearance
Ethical clearance was sought after and obtained from Queensland University of Technologies’ Human Research and Ethics committee prior to the commencement of data collection (ethics approval number 1600000040). The study was considered low risk and informed consent was collected from all participants recruited. Participants voluntary agreed and consented to the interviews being audio recorded. All data was kept securely with the hard copies locked in a QUT locker and softcopies password protected. Any identifying information was removed, and all participants were assigned an alias to ensure anonymity.
3.9 Chapter Summary
This chapter has detailed the research design, data collection and method of analysis. The research paradigm of constructivism with a subjectivist epistemology was discussed and supports the choice of a qualitative investigation. The sampling, data collection techniques and process of analysis were outlined and justified. The following chapter will discuss the results obtained from implementation of the method and will be followed by the theoretical and managerial implications in Chapter 5.
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Chapter 4: Results
4.1 Introduction
This chapter discusses the findings derived from the thematic coding and analysis of data collected through semi structured interviews and projective techniques. The chapter begins with a profile of the sample, then the participants’ general attitudes towards condom use are discussed as a prelude to analyzing the research questions. Research Question 1 (RQ1) is addressed through the exploration of the participant’s lived experiences and sexual scripts. Themes within cultural, interpersonal and intrapsychic scripts were identified using semi structured interviews to explore their lived sexual histories. Key themes pertaining to how sexual scripting influences protective sexual behaviors specifically condom use is then discussed. Research Question 2 (RQ2) is then answered through incorporation of these lived sexual experiences and analysis of psycho-drawings to understand the customer experience of protective sexual behaviours. Elements of the customer experience are identified and classified as barrier and or motivators for prophylactic condom use. Key themes pertaining to how the customer experience influences protective sexual behaviors specifically condom use is then discussed. Finally, methodical observations are considered followed by the chapter summary.
4.2 Sample Characteristics
The participants of this study were Australian, aged between 50-70 years old and self-identified as heterosexual, single (not in a long term or committed relationship) and sexually active. Figure 14 and Figure 15 outline the demographic characteristics of the participating mature adults. These figures include the participants’ fictitious name, age, suburb, experience with condoms, relationship status and how long they have been on the market dating. Of the participants 2 females (8.3%) and 1 male (4.1%) had never used a condom previously. Five participants (2 males, 3 females, 20.8%) stated that they used condoms when they were younger and 3 (2 males, 1 female, 12.5%) stated that they always used a condom with every sexual partner. The remaining 14 participants (58%) stated that they “occasionally used condoms” which was mainly determined by their partner or situational factors. Most of the sample also
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identified as being single due to either separation (3, 24%) or divorce (15, 62.5%). One participant did identify as a widow however this occurred in her youth and she later remarried and then became divorced.
Figure 14. Male Sample Characteristics
JASPER ALBERT THEODORE 58 59 61 Woodridge, QLD Morningside, QLD Slack Creek, QLD Never Uses a Condom Used Condoms When Younger Used Condoms When Younger
Divorced 13 years Divorced 4 years Single 36 years
HAROLD RALPH BERNARD 66 59 58 Tarragindi, QLD Springwood, QLD Hobart, TAS Occasionally Uses Condoms Occasionally Uses Condoms Occasionally Uses Condoms
Single 50 years Single 36 years Divorced 2 months
XAVIER MONTY STANLEY 59 64 Everton Park, QLD 50 Herston, QLD Forresters Beach, NSW Occasionally Uses Condoms Occasionally Uses Condoms Occasionally Uses Condoms
Separated 4 months Divorced 2 years Divorced 4 years
LIAM KEITH ULRICH 56 55 57 Brisbane, QLD Enoggera, QLD Sydney, NSW Occasionally Uses Condoms Always Uses Condoms Always Uses a Condom
Divorced 7 years Divorced 5 years Divorced 8 years
*Names and suburbs within the postcode have been changed to preserve anonymity
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Figure 15. Female Sample Characteristics
IRENE QUINN CELIA 70 61 57 Chermside, QLD Bondi, NSW Ferny Hills, QLD Has Never Used a Condom Has Never Used a Condom Used Condoms When Younger
Divorced 35 years Divorced 7 years Divorced 5 years
VIVIAN GWENDOLYN FLORENCE
54 61 61 Hornsby, NSW Fairfield, QLD Nudgee, QLD Used Condoms When Used Condoms When Occasionally Uses Condoms Younger Younger
Single 15 years Divorced 10 years Single 18 years
WILHEMINA OLIVE DOROTHY 57 62 51 Virginia, QLD New Farm, QLD Ascot, QLD Occasionally Uses Condoms Occasionally Uses Condoms Occasionally Uses Condoms
Single 41 years Divorced 5 years Separate 6 years d
NELLIE ESMERELDA PEARL
51 66 60 Sherwood, QLD Northgate, QLD Melton, VIC Occasionally Uses Condoms Occasionally Uses Condoms Always Uses a Condom
11 years Divorced 40 years Separated 5 years Divorced
*Names and suburbs within the postcode have been changed to preserve anonymity
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4.3 Condom Attitudes and Use
The purpose of this section is to outline participant attitudes towards condoms and contextualize their use as a protective sexual behaviour. Perceptions of relevance and risk of pregnancy and disease are also discussed. All participants understood what a condom was; however, attitudes towards them, and perceptions of their purpose varied within the sample. Figure 4.3 summaries the sample’s attitudes towards condoms using direct quotes. The figure starts with the two female participants who have never used a condom in their life. This is followed by positive, indifferent and then negative attitudes towards condoms and their use. As seen in Figure 16 attitudes towards condoms were predominantly negative by both men and women with them described as “irritating, passionless, yucky and unnatural”. Those who’s attitudes were indifferent towards condoms did not specifically like them but viewed them as either a necessary evil, requirement of sex or dependent upon their sexual partner. Overall women were more favorable towards their use though this came with the backhanded comment that despite their positive attitude, men were still reluctant to use a condom:
“I always worry about the health things, but guys seem a bit less concerned about the health… They just don't wanna use a condom” Dorothy, 51
“Men don't like using, they are embarrassed by putting them on, there embarrassed by taking them off they complain nonstop” Nellie, 51
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Figure 16. Attitudes Towards Condoms
"I don't really like them, “Oh, I liked them "I find them very “Never used them, in my but I know they're a [condoms] but my ex- irritating. They cause era, we got married it necessity." husband didn't like friction burns on me." wasn't the thing anyway, Pearl, 60 Nellie, 51 them." Celia, 57 and most people didn't basically have sex; well, I “I don't have an issue "They are passion-less!" “They're fine, you know, didn't.” with condoms. It’s Florence, 61 you can make it into a Irene, 70 personal preference …up game, make it Never [used a to individuals” “…. it's like missing the pleasurable for both condom] …. it’s funny to Esmerelda, 66 skin to skin contact.” people to use.” think about now but it’s Olive, 62 true. You never spoke Vivian, 54 “It’s a barrier to keep us about the need, there was “I think they’re great. safe, pretty much." “Using an old cliché but no talking. I’ve always got them. I Gwendolyn, 61 it's like having a shower Quinn, 61 think men are reluctant to with a raincoat on.” use them.” “I don’t carry them… it's
Dorothy, 51 like do you have anything, and they go no, Bernard, 58 & “If it's handled properly Monty, 64 and you go oh well.” it can be very intimate." Wilhelmina, 57 Xavier, 59 “I must admit I find “I don't like wearing them no, I sort of see condoms a bit yucky.” Harold, 66 them as a bit of a necessary evil.” Stanley, 50 I'm not satisfied because you're feeling nothing” Jasper, 58 “Like I said its partner dependent if they say use it …then use it. It's not a "I find it unnatural. To problem." me it becomes like a Ralph, 59 surgical thing.” Albert, 59 I mean, I don't like using them, but I have to" “They interrupt the Ulrich, 57 natural flow.” Keith, 55 “Condom use... I've never bothered with them “I hated it. From the first all that much.” experience. I just Theodore, 61 thought, 'I don't like this at all.” Liam, 56
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4.3.1 Condoms the Second-Class Contraceptive
Unsurprisingly condom use within the sample was primarily aligned with contraception and protection from pregnancy:
“The reason that you use them was not for sexual health reasons. It was more so that you didn't get someone up the duff.” Liam, 56
“I think my era it was mainly that it was for not getting pregnant but then I was the age of the contraceptive as well. So, there was other options. It wasn't in terms of STDs” Florence, 61
Despite the acknowledged contraceptive properties of condoms, participants were reluctant to use them during their reproductive years as advancements in contraceptive choices allowed other options. One participant even expressed that they would rather risk pregnancy than use a condom:
“Either I've been on the pill or we've decided not to use them [condoms]. I mean, that's how I got pregnant.” Dorothy,51
Participants stated the most commonly used condoms between the births of their children and until an alternate method of contraception could be used:
“Once we'd had the children, we decided we didn't want any more, I tried to go onto the Pill and it just...oh, I had awful side effects... So we used condoms” Pearl, 60
“…only other time was um, during my marriage, it was in-between babies” Albert, 59
Alternative forms of contraceptives to condoms used by participants during the reproductive stages of their lives are listed in Table 11 with supporting quotes.
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Table 11. Contraceptive Choices
Contraceptive Quotes The Pill “I was on the Pill before we decided to have A daily oral tablet (also known as the children.” combined pill or oral contraceptive pill) Olive, 62 contains two hormones oestrogen and progestogen. “There was no need to use condoms when she was on the Pill”
Xavier, 59 Injections “See my contraception was depo provera.” Wilhelmina, 57 Contraceptive injection (also called
Depo), is an injection of the hormone “Yeah, she got birth control; the injection, I Hormonal progestogen. Progestogen is similar to the think?” hormone produced by the ovaries. Jasper, 58
Intrauterine Device (IDU) Intrauterine “Oh yeah yeah the pill and for a few years I device is a T-shaped birth control that is had IUD and, never thought about using inserted into the uterus to prevent them [condoms].” pregnancy. Quinn, 61
Female Condom “My previous long-term partner actually
used, I forget what it's called now, it was like The female condom is a soft pouch made a version of the female condom.” of latex or polyurethane, that has two Stanley, 50 flexible rings at each end. It is inserted
into the vagina or anus before having sex. Diaphragm
Barrier The diaphragm is a shallow, cup-shape “She said…I’m on the pill or I've got a made of silicone. The diaphragm may be diaphragm”. inserted up to two hours before having Ralph,59 sex. It must stay in place for at least 6 hours after sex.
Rhythm Method “She was very precise with her cycles, so we The rhythm method also known as natural used to plan our sexual activity around that family planning or fertility awareness is cycle.” Albert, 59
avoiding sex around the time of the month where the female is fertile (most likely to get pregnant)
Withdrawal Control
- “I know how to control myself. They call it withdrawal.” Self The practice of withdrawing the penis Jasper, 58 from the vagina and away from a woman's external genitals before ejaculation to “They train themselves to, to not emit……to prevent pregnancy not ejaculate...” Theodore,61 (Family Planning Victoria, 2020)
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Ultimately some participants felt that once they had finished the procreational stage of their life, surgical sterilisation via tubal ligation or vasectomy became an option:
“I'd had my tubes tied.” Celia 57 & Nellie, 51
“I actually did get the snip too. So, after we had our kids, the condom situation just became not an issue” Ulrich, 57
“He tells me he's had a vasectomy, and then I always worry about the health things, but guys seem a bit less concerned about the health.” Dorothy, 54
The use of surgical sterilisation to remove all risks of pregnancy is another potential contributing factor to HMA low perceived risk and susceptibility to STIs.
4.3.2 Awareness of STI and Perceived Risk Moving away from contraception, discussion of risk and disease found that 14 of the participants (58%) believed that were not at any risk of contracting an STIs. Two participants (8%) admitted to some risk of contracting an STI if their partner lied. The remaining 7 participants (29%) believed they were at risk of potentially contracting an STI with gonorrhea, chlamydia, herpes, human papilloma virus and pelvic inflammatory disease considered to be the riskiest.
Through the analysis of participants attitudes towards condoms it is evident that condom use was associated with contraception (Braun, 2013; Sanders et al., 2012). This study has contextualized condom use through participants lived experiences identifying condoms as the least preferable of contraceptive choices, especially by men. For most participants condoms have been a necessary evil at some point or another and or substitute until a preferable/long-term contraceptive solution is found. While there is some awareness of STIs most participant’s perceptions of risk are low as they believe that they have excellent judgment in selecting sexual partners. The following section aims to understand participants’ sexual scripts and how these drive the protective behavior of prophylactic condom use.
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4.4 How do psychosocial scripts influence condom use behaviour by heterosexual mature adults?
To answer RQ1, participants were asked about their lived sexual history, past relationships, protective sexual behaviours (contraceptive and prophylactic) and the purpose of sexual activity across their lifetime. Questions drawn from sexual scripting theory (Simon & Gagnon, 1984) were used to understand participant’ protective sexual behaviours and condom use. SXS (Simon & Gagnon, 1986; Wiederman, 2015; Wiederman, 2005b) denotes that sexual scripting is the interplay between the dimensions of culture (cultural scenarios), the individual (interpersonal scripts) and finally aim of the sexual activity (intrapsychic scripts). The first step of this research was to identify the interplay and layering of participants sexual scripts (Figure 17). This research identified that the historical events within cultural scenarios are shared by both male and female HMAs. However, sexual norms and gender role were found to be specific to each participant and their life experiences. The same was found for interpersonal script with past experiences, partner type and interpretation of sexual cues being distinctive to each participant. Finally, when analysing intrapsychic scripts commonality was found with both male and female participants with all sharing the need for fantasies, intimacy and arousal.
Figure 17. Heterosexual Mature Adult Sexual Scripts
Cultural Scenario Cultural Scenario
Gender Role Sexual Norms
Historical Sexual Norms Events Interpersonal Interpersonal Gender Role
Past Experiences Intrapsychic Past Experiences Partner Fantasies Partner Interpretation Intimacy Interpretation Arousal
Once the interaction of participant’s sexual scripts was identified analysis was conducted to identify the underlying mechanisms of each script. Three mechanism were found explain how psychosocial scripts of HMAs influence the protective sexual behaviours of mature adults during casual sexual encounters: the positioning, practice
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and purpose of sex. The following sections will discuss each of these mechanisms and how they explain heterosexual mature adult protective sexual behaviour. This is then followed by discussion of the subsequent themes also identified within the data; script misalignment and the role-reversal of power in sexual relationships.
4.4.1 Positioning of Prophylactic Protective Sexual Behaviour: Power, Relevance and Obsolescence This research has identified that the positioning of HMA protective sexual behaviours is framed by power, relevance and obsolescence. Each of these antecedents to positioning has the ability to motivate or form a barrier to the behaviour (Table 12). Following the table each mechanism will be discussed and represented conceptually (Figure 20).
Table 12. Positioning of Prophylactic Protective Sexual Behaviour
Positioning of Behaviour
Power Relevance Obsolescence Females are gatekeepers One-night stand, casual partner Health Promotion responsible for protective & first time sexual behaviours (primarily World War II “I know when my ex was on the contraception) “Gonorrhea was a big thing dating site, he did use a lot of those day, they advertise it on
“Yeah its pretty much condoms…. his expectation is a one
considered my responsibility. night stand or a few nights stand.” TV, it was awful…. Well it was a dribbly penis…… it was pretty They don't even ask; I mean Celia, 57 not even when I was still scary stuff.” Harold, 66 fertile.” Nellie, 51 “If you where just going to sleep Grim Reaper with someone, have a one-night
Motivators “The Grim Reaper program was “I think the fact that stand with someone you've met at doing as well. There was that pregnancy only takes place in Kings Cross or up the Valley, fear side of things as well, you a female's body, there is there's a good chance you might know, that he was so grim, but actually more responsibility on get something.” Monty, 64 that it could be anybody that is women than there is on men.” affected by it.” Vivian, 54 Stanley, 50 Males are aggressors and Asexual old age Contraceptive devices sexually dominant “I just think well I can't have “It was the age of “My ex-partner refused to children I'm past menopause so no. contraceptives…. So, there was wear a condom. He refused.” I think the education for our age other options.” Florence 61 Dorothy,51 bracket need to come back into AIDs Pandemic focus” Gwendolyn, 61 “Well, he didn't want to use a “I'm old enough to remember condom either, so that's why I Condoms are for “Young people” when AIDS epidemic really took had another pregnancy.” “I think [condoms] they're useful over in Australia, there was a lot Celia, 57
Barriers Barriers for the younger generation.” Celia, of advertising around that time.
57 ….it didn't scare me.” Stanley, 50 & “Gay people” “I'm not really worried about “All you need was one trans sexual HIV and AIDS.” Nellie, 51 and bugger up a whole community.” Ralph, 59
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Power When exploring gender role, power was identified as an antecedent of prophylactic protective sexual behaviour. Gender role is binary in heterosexual relationships and thus power as an antecedent is also dualistic in nature with each the male or female sexual partner able to facilitate or inhibit prophylactic condom use (Broaddus et al., 2010; Wiederman, 2005). While many participants felt that condom use was a joint responsibility:
“I think that's the case, where pregnancy isn't an issue, I think both are responsible for the same, you know, for the health.” Harold, 66
The ideology of mutual power and the joint decision to use a condom was not the reality. Power resulting from gender roles were found to position the responsibility of purchasing, negotiating and using a condom for prophylactic purposes. With whom the responsibility of this process lies is where confusion occurs between sexual partners. Discussion with participants revealed that within their sexual encounters one partner would be more dominate than the other. This dominance enabled the execution of power which either facilitated or inhibited prophylactic condom use. Traditionally gendered power lies with the woman as they are gatekeeps to the sexual activity and have historically been responsibility for contraceptive choices (Goldin & Katz, 2002):
“So the whole generation of men is just like nah sexual health everything, it's all the woman's job it's my job just to get in there.” Nellie, 51
Thus, when traditional gender roles are enacted with the power and responsibility being the woman’s, she can either motivate:
“I have had women who have said, 'I'm not going anywhere near you unless we use a condom.” Liam, 56
or inhibit prophylactic condom use:
“Oh, no, and then they say, 'should I use a condom?' and I go, 'nuh, it's fine.' But, there's still a little bit of uncertainty on the male side. Some of them think, 'oh, hang on, are you sure? Are you positive?' and I'll say, 'yes, I've had my tubes tied.' 'But are you positive?' 'Yes, I am.” Celia, 57
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“I was dating an older person than me and she was really ... she kept on saying, 'look, I don't want to have sex with that damn thing.'… A real ball buster.” Ulrich. 57
Power in the form of masculinity was also found to position condom use negativity. Male participants articulated that there are sexual acts that are more masculine than others. Penetration using the penis was considered be the physical goal of the sexual activity and using a condom is ultimately a barrier to this.
“Penetration is the word I was looking for... I'm a natural dude man it’s only supposed to go where it's supposed to go” Albert, 59
Women furthered this argument with many stating that their ex-partners believe that any form of protective sexual behaviour (prophylactic or contraceptive) was not the manly thing to do:
“He just ... it was not a manly thing to do and men don't do it, and he just said, 'I'm not going to do it. I'm a man and I don't have to.” Celia,57
The sexuality and scripting literature confirm that gender role helps makes sense of and shapes sexual behaviours (Wiederman, 2005; Woolf & Maisto, 2008). Males are the aggressors that pursue the female who as a gatekeepers to the sexual activity consents and then the male sexually dominates (Wiederman, 2005). While this research did find evidence of the enactment of traditional gender roles within HMA sexual encounters this did not explicitly predict or explain prophylactic condom use. This research found that gender role helped to position power within the sexual encounter and dictates who is responsible for condom use. This became particularly apparent for when there is a script misalignment (section 4.4.5) between sexual partners or a reversal of power (section 4.4.6).
Relevance When exploring sexual norms, relevance was identified as an antecedent of prophylactic protective sexual behaviour. Relevance explains the perceptions of appropriateness of condom usage by HMAs. Relevance of condom use was expressed by participants through discussion of ageist attitudes and type of sexual encounter. Sexual norms for mature adults as dictated by society are ageist and therefore, HMAs should not/ do not have sex (Thompson, O’Sullivan, Byers, & Shaughnessy, 2014).
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This positions condoms as irrelevant to mature markets and thus forms a barrier to their use. Participants themselves expressed that condoms are more for younger consumer markets:
“I think [condoms] they're useful for the younger generation.” Celia, 57
The effort to conceals the planning and process of condom use to avoid notice and conform with ageist social norms may also form a barrier for mature adults. Funnily enough participants themselves even expressed ageist attitudes towards their own parents’ sexual activity:
“My parents I don't think ever had sex after the age of about 45...” Albert, 59
Sexual norms around the type of sexual encounter was also found to position and either motivate or form a barrier to condom use. One-night stands and first sexual encounter with a partner were stated to be potential motivators for condom use by participants as social norms dictate this as appropriate.
“If I thought I was going to be in a situation where I thought I was going to be having sex with someone for the first time I would have them with me.” Stanley, 50
However, despite this once again participants actual behaviour did not reflect their discussion. Most if not all participants believed that they were excellent judges of character and were careful with whom they slept with.
I'm just really careful in who I go with and I get to know them a bit and make
sure they haven't got anything” Celia, 57
Despite acknowledgement of risk and confrontation by the GP about their behaviour participants still were reluctant to use a condom:
“It's been a lot of fun, but my GP lectures me. I've been really bad about not using condoms because I hate them, and I just think I've been really lucky.” Liam, 56
The sexuality and scripting literature confirm that sexual norms influence sexual behaviours and that there are ageists attitudes towards mature sexuality (Gagnon, 1990). This research has identified that surprisingly mature participants themselves have ageist attitudes towards their own parents’ sexuality and that they do not perceive
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themselves as mature despite physiological changes. Paradoxically it is these changes and ageist attitudes that position condom as irrelevant to them as a consumer market. While participants acknowledged the relevance of condom use for first time or casual sexual encounters this did not reflect their own behaviour.
Obsolescence When exploring historical events, obsolescence was identified as an antecedent of prophylactic protective sexual behaviour. Obsolescence is the perception that condoms are useless and impractical. Participants identified that advancements in STI treatment and more sophisticated contraceptive devices has positioned condoms as unnecessary, outdated and even last resort.
“Unfortunately, you know ah, he did get a disease…. And um, but it was treated...” Xavier, 59
“It was the age of contraceptives…. So, there was other options.” Florence, 61 Obsolescence of condoms were demonstrated through low perceptions of risk. While participants had vivid memories of STI social advertising from World War II venereal disease propaganda (Figure 18) and The Grim Reaper AIDS campaign (Figure 19) there was limited impact on behaviour.
Figure 18. World War II Figure 19. Grim Reaper
Source (Serlin, 2010)
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Discussion found that old world STIs (syphilis & gonorrhea) were an inconvenient but treatable thing form the past that that did not apply to them:
“Syphilis or gonorrhoea. They were from a previous era and almost as if they had been wiped out... They didn't exist anymore, and we know they do. But you know they just didn't exist, they weren't a issue” Florence, 61
Similar attitudes towards HIV/AIDS were expressed by participants. The literature traditionally frames AIDS as a motivator to prophylactic condom use (Chin, 1990). However, this research has found that for HMAs the AIDS epidemic had little impact on their past or current behaviour. Despite acknowledgment of fear, risk and proximity.
“My friend would just sleep with anyone, and good luck to her; we don't judge, but her sister died of AIDS.” Dorothy, 51
It was also identified that there was miscommunication abouts AIDs transmission in this cohort with one participant stating that he and his mates used to believe that you could contract AIDS from having anal sex with their wives, despite being in monogamous relationships.
“No no-one ever mentioned I think in the 80's that if you have anal sex with your wife will you get AIDS” Xavier, 59
As previously discussed, condoms have primarily been positioned throughout HMA’s lives as a contraceptive. Starting with the pill, historical events have seen advancements in pharmaceutical and physiological contraceptive technologies and consequently positioned condoms as an outdated relic. This combined with low perceptions of risk leads to condoms as obsolescent to mature consumer markets. They are no longer a necessity and as such these perceptions may form a barrier to use.
To summarize Power, Relevance and Obsolescence as antecedents to cultural scenario combine to position protective sexual behaviours for heterosexual mature adults (Figure 20). This positioning frames the responsibility, appropriateness and necessity of using a condom and can either motivate or form a barrier to prophylactic condom use behaviour.
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Figure 20. Positioning of Prophylactic Protective Sexual Behaviour
Power Positioning Motivator of prophylactic Relevance protective sexual behaviour
Obsolescence
Barrier
4.4.2 Attitude, Risk and Permission: Interpersonal Antecedents of Condom Use This research has identified that the practice of HMA protective sexual behaviours is formed from the HMA’s attitude towards condoms, perceived risk and permission given to perform the behaviour. This practice has been formed from the HMA’s lived experiences and phenomenological recall of similar situations. Each of the antecedents to practice has the ability to motivate or form a barrier to the behaviour (Table 13). Following the table each mechanism will be discussed and represented conceptually (Figure 21).
Table 13. Practice of Prophylactic Protective Sexual Behaviour
Practice Attitude Risk Permission Good Condom Experiences Unfamiliar Partner Prior Discussion
“I usually find the men are “Yeah, at least a month and “It just depends on the person pretty good. Yea. Most guys are maybe a two before stopping as well, because if you have pretty... Mature guys.” using [condoms].” Dorothy, 51 discussed condoms with this Esmerelda, 66 “If it was a new partner, person before, then there's no
obviously I wouldn't know that issue”. Ulrich, 57 “I think it's a bit of an urban straight away so it would Motivators myth that your sexual pleasures certainly be a case of dependent aren't as intense. I certainly upon my partner, and how well I haven't found any problems with knew them.” Stanley, 50 that.”Vivian, 54 Bad Condom Experiences Education & Hygiene Silence
“The demographics that I sleep “It's difficult for me to have a “Condoms have always been
with are not extremely low. Yep conversation because I think something that sort of been fairly tertiary educated men.” they have more power but unnatural.” Albert, 59 Nellie, 51 that’s so silly because I'm
very independent… well not “I've had a condom break and “I tell her, I said to her, my
Barriers making a fuss, not making a the woman was obviously quite country, all of the women are fuss so that compliance.” upset.” Stanley, 50 clean” Jasper,58 Gwendolyn, 61
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Attitude When exploring past experiences, attitude was identified as an antecedent of prophylactic protective sexual behaviour. Attitude is the way in which a HMA thinks and feels about using a condom. These attitudes have been formed overtime and are a combination of salient beliefs about the outcome of condom use and direct experiences both prophylactic and or contraceptive (Albarracín et al., 2001). Ultimately this means that if a HMA believes that using a condom will negatively impact their sexual experience and have had negative experiences with condoms they are less likely to use one in the future.
“You can be frustrated, because sometimes the erection can fade away, and that was a first-hand experience for me.” Keith, 55
“It certainly, I find, it makes it more difficult to maintain an erection for instance.” Stanley, 50 The same association was found for positive beliefs and positive past experiences. The relationship between attitude and condom use has been extensively discussed within the sex and sexuality literature and is considered a primary determinate of condom use (Davis et al., 2014). This research has found that for HMAs attitude is still a mechanism of prophylactic condom use but it is only one component of a more complex paradigm. This complexity is the result an accumulation of sexual experiences across each HMAs life course and the creation of new shared sexual experiences.
Risk When exploring the element partner, risk was identified as an antecedent of prophylactic protective sexual behaviour. Risk is a combination of the perceived severity and susceptibility to contracting a STI (Anderson, 2003; Sheeran et al., 1999). As previously discussed, new or casual sexual partners are deemed socially relevant to condom use by HMAs, but this does not necessarily increase condom use behaviour. Similarly, this research has also found that HMAs do not perceive themselves to be at risk of contracting an STI. Severity and susceptibility have been well documented in the health literature (Shearer, Hosterman, Gillen, & Lefkowitz, 2005; Sheeran et al., 1999; Sheeran & Taylor, 1999). This research has extended this work by identifying three factors that contribute to HMA’s low perceptions of risk: education, cleanliness
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and time dating. Participants were found to believe that higher education is associated with lower risk of contracting an STI and as such a condom is not needed.
“The demographics that I sleep with are not extremely low. Yep tertiary educated men.” Nellie, 51
“I’m not hanging around with slappers, these are intelligent, professional women” Liam, 56
Appearance, grooming and genital hygiene were also found to influence perceptions of risk.
“If they are Disease free…… you assume they’re clean” Nellie, 51
Finally, the time some has been dating was found to influence HMA perceptions of risk. This research found that if a woman has been in a marriage/long-term relationship they are perceived to be safe by men.
“I’m like aren't you worried that you might catch something from me? They all seem to think that I've stepped out of a marriage and haven't had sex with anyone else and that you know I couldn't possibly gotten anything from my husband either. They think they immune.” Nellie, 51
Women on the other hand did not believe the same of men with most sceptical of their male partners.
“A lot of men I know travel, and particularly with Bruce*…he works in this road crew sort of thing, they install guard rail around Australia, and they go away and they're all playing up; all the married ones and everything. That's why I don't ... that's one of the reasons I don't want a relationship. Even though I trust the disease thing, I don't trust men.” Dorothy, 51
*name changed to preserve anonymity
Permission When exploring interpretation, permission was identified as the antecedent of prophylactic protective sexual behaviour. Interpretation is how a mature adult makes sense of the signs, symbols and actions within the sexual experience with their partner. Discussion with HMAs identified that prior discussion and negotiation of condom use increased the likely hood of a condom being used:
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“But like I said, it just depends on the person as well, because if you have discussed condoms with this person before, then there's no issue.” Ulrich, 57
However once again individuals expressed that even with the best of intentions and prior agreement to use a condom the prophylactic condom use behaviour is not performed:
“Sometimes it gets discussed with women beforehand, and then it just gets ignored in the heat of the moment.” Liam, 56
When condom use is not discussed prior to the sexual activity the ambiguity of the situation can cause a stalemate whereby neither of the mature adults know whether to propose condom use and a “silence” occurs. This silence is most commonly interpreted as permission to not use a condom.
“…Well not making a fuss, not making a fuss so that compliance” Gwendolyn, 61
“Not many men do carry them….. No, they wait to be asked and they just think they can get away with it”. Wilhelmina, 57
There's never any would you mind using a condom. Well not my situation yeah they just put them there and I say well I guess she wants me to use a condom, fine…… But if its not mentioned, I think its just. It doesn't happen.”Harold, 66
To summarize Attitude, Risk and Permission as antecedents to interpersonal scripts combine to explain the practice of protective sexual behaviours of heterosexual mature adults (Figure 21). This practice is framed by the personal experiences HMAs have had with their previous sexual partners and condom use. These prior experiences are used to make sense of the sexual encounter and thus motivate or form a barrier to current and future prophylactic condom use behaviour.
Figure 21. Practice of Prophylactic Protective Sexual Behaviour
Motivator Attitude Practice of prophylactic Risk protective sexual behaviour
Permission Barrier
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4.4.3 Desire, Connection and Gratification: Intrapsychic Antecedents of Condom Use This research has identified that the purpose of HMA sexual behaviours is driven by desire, connection and gratification. These mechanisms are not antecedents to the script but rather articulate the anticipated experience outcome. This differs as the anticipated outcome of the sexual experience is shared by both sexual partners. Condoms function as a barrier to protect and as such form a barrier to the anticipated shared experience. Therefor motivators and barriers for the intrapsychic script are directly linked to the physical product (male condom) rather than the behaviour. Barriers were identified as ways in which the condom inhibited or distort the objective of the anticipated shared sexual experience (intrapsychic elements) and motivators were ways in which participants attempt to overcome these barriers. Table 14 outlines this process with direct quotes from participants. Following the table each of the mechanisms are discussed and presented conceptually (Figure 22).
Table 14. Purpose of Sexual Experience and Prophylactic Condom Use Purpose Desire Connection Gratification Fun Skill Respect
“Oh, I think they're fine, you “You know, it can be a very “I think it's just a...as a sign know, you can make it into a intimate experience with your of respect I think.” Xavier, 59 game, you know, make it partner… because it's a dual
pleasurable for both people to act...” Xavier, 59 “It can be looked at as being use. There's no dramas with respectful and considerate.” Motivators that” Vivian, 54 Florence, 61
Disrupts Contact Pleasure
“skin you know, like you...it's “Women just don't use them. “I think um, just the condom's an
like missing the skin to skin They prefer not to. They want extra step so...” Albert, 59 contact...” Olive, 62 the feel and touch.” M11
“It does interrupt the “It can be actually be a bit more “It's just using an old cliché flow”Monty, 64 joyful. You know because there's
Barriers but it's like having a shower been connection.” Florence, 61 with a raincoat on.” “I just stopped and think about Benard,58 what you're doing... It
interrupts”. Florence, 61
Desire When exploring the element fantasies, desires was identified as an anticipated outcome of the shared sexual experience. Desire is how the sexual experience is envisioned across the sexual response cycle; excitement, plateau, orgasm and
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resolution (Masters & Johnson, 1966). The shared sexual experience must accommodate both sexual partners desires across all four phases of the sexual experience. Therefore, if condom use is perceived to inhibit or distort the envisioned experience for either partner at any phase then condom use is unlikely. Participants described the optimal shared sexual experience as one that was a natural progression and seamless.
“It's instant pleasure, for both parties. There's no ripping off the condom, pulling it out. Yeah, it's seamless. Seamless interaction.” Keith, 55
Participants primarily expressed frustration with condom use during the first phase of the sexual cycle (excitement) as they were perceived as an extra step that interrupted the natural flow of the experience:
“Knowing that you've gotta actually go through...rip the packet open and then...you know ah, that, that kind of...and it's coitus interruptus.” Bernard, 58
Therefore, for a condom to be used correctly and consistently during the sexual activity it must be incorporated in a way that is seamless and adds value to the shared experience:
“You know together, putting it on together so it's...if it's gonna be involved in the, in the process [Interviewee says "Yep"] it's gonna have to be um... Eroticised and it's also gonna be you know ah, seamless.” Albert, 59
Some participants stated that condoms use made the orgasm and resolution cleaner:
“I know one thing I do like about condoms, and that is a condom is instant cleanliness. You do not have a woman dripping seamen out of them. You don't have to worry about going and getting a towel. I can take it off, tie a knot, have a quick brush down and it's done, you can have a nice cuddle” Keith, 55
Prior sex and sexuality research have predominantly focused on perceptions towards condoms and rates of use. This research has identified that the desired shared sexual experience for HMAs is one that is natural and paradoxically a condom is not natural. Therefore, if condom usage is to increase then the process of application, usages, removal and disposal needs to add value to the envisioned experience.
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Connection When exploring the element of intimacy, connection was identified as an anticipated outcome of the shared sexual experience. Connection is the shared physical and emotional expression of the sexual relationship. Connection was identified as one most important reason for having sex by participants:
“Your looking for what do you call it (laugh) your looking for, your looking for the connection, where your feeling everything.” Monty, 64
“I want connection I want, Im very affection, very touchy feely I love holding hands with I like I don't like doing anything in front of people I know. I'm quite happy to kiss in public in front of other people.” Nellie, 51
The need for connection and intimacy was even seen to surpass physical pleasure and orgasm:
“If I wanted an orgasm I'd wank in a flannel. Um, I can have an orgasm anytime.” Albert, 59
Unsurprisingly participants felt that condoms were an obstacle to connection as stopping to get the condom ruins the moment and puts a physical barrier between the sexual partners:
“By the time I mentioned, 'I'm going to go and get a condom,' she would just lose that bit. So, I just said to her, 'look, it's a safety thing and I don't know you. I don't really know you. I mean, I know you, what I see and what I know of you, but I don't know who you've slept with.' If you bring that up, that just ruins the night, then you're asking them, 'who have you slept with or whatever.' You just don't want to talk about history in that moment. You just want to go for the moment, not the history.”Ulrich, 57
One male participant believed that condom use could be intimate and not interfere with connection however this requires the shared desire to use one:
“You know, it can be a very intimate experience with your partner… because it's a dual act...” Xavier, 59
The sex and sexuality literature acknowledge and support the positive health outcomes resulting from human connection and physical intimacy (DeLamater, 2012;
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Marshall, 2011). This research validates the significance of intimacy to HMAs and has identified that shared physical and emotional connection is the anticipated outcome of the sexual experience.
Gratification When exploring the element of arousal, gratification was identified as an anticipated outcome of the shared sexual experience. Gratification was expressed through the shared accomplishment of sexual pleasure and orgasm. Achievement of this helps HMAs evaluate the sexual activity and overall satisfaction with the experience. Condom use was stated by both male and female participants to inhibit orgasm and reduce the pleasure of the sexual experience.
“That's exactly right because its going to be bad sex because I've already got a doubt with Impotency so that's only going to heighten all the doubt I have.” Monty, 64
Male participants were especially concerned with this aspect of condom use as they expressed a sense of accomplishment from pleasuring their female partner and educing an organism.
“as long as she enjoys it, I enjoy it too, you know?” Jasper, 58
“For me, the most important thing is that the woman has an orgasm and she is enjoying the situation.” Albert, 59
Only one female participant was found to associate condom use with gratification as she saw a male offering to use a condom as a sign of respect and this relief enabled her to enjoy the sexual experience:
“this has been owned by him and it makes you feel more, less worried…it's showing a respect yeah…”Gwendolyn, 61
Another male participant echoed this sentiment associating condom use with respect:
“I think it's just a...as a sign of respect I think.” Xavier, 59
The sex and sexuality literature confer that condoms are perceived to inhibit sexual pleasure and thus is a barrier to their use (Braun, 2013). This research has
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identified that gratification is a shared mechanism for HMAs that help them to evaluate their satisfaction with the sexual experience. Thus, if using a condom inhibits or distorts the anticipated gratification outcome for either of the mature adults then the sexual experience is considered to be deficient and continued/future condom use is unlikely.
To summarise Desire, Connection and Gratification combine to form the anticipated shared experience outcome of the intrapsychic script and purpose of performing the sexual activity (Figure 22). The following section will conceptualize how the positioning, practice and purpose created by psychosocial scripting explain heterosexual mature adult prophylactic protective sexual behaviour.
Figure 22. Purpose of Sexual Experience
Motivator
Desire Purpose of sexual Connection behaviour
Gratification Barrier
4.4.4 Positioning, Practice and Purpose: Explaining Heterosexual Mature Adult Prophylactic Protective Sexual Behaviour Through the exploration of the mechanisms that underpin participants psychosocial sexual scripts a conceptual model was developed to answer research question 1 (Figure 23). All three scripts were found to either motivate or inhibit prophylactic protective sexual behaviour. Positioning (power, relevance, obsolescence) and Practice (attitude, risk, perception) were found to shape participants perceptions of prophylactic protective sexual behaviour. These perceptions help mature adults navigate whether prophylactic condom use may enhance, inhibit, distort or have no effect the anticipated outcome of the sexual experience. The anticipated experiential outcome formed the Purpose (desire, connection, gratification) and was found to be the most important element for participants when navigating prophylactic sexual behaviour. Thus, if prophylactic
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condom use was perceived to inhibit or distort the anticipated outcome of the sexual experience then engagement with the protective sexual behaviour (condom use) is unlikely. Conversely if prophylactic condom use is perceived to enhance or have no effect on the purpose of the sexual experience then HMAs are more likely to engage in protective sexual behaviour.
Figure 23. Conceptualisation of Heterosexual Mature Adult Prophylactic Protective Sexual Behaviour
Power Positioning of prophylactic Relevance protective sexual behaviour Obsolescenc e Purpose of Sexual Activity Desire, Connection & Gratification Heterosexual Attitude Practice of prophylactic mature adult’s
Risk protective sexual engagement in behaviour protective sexual
Perception behaviour
4.4.5 Positioning, Practice and Purpose: Explaining Heterosexual Mature Adult Prophylactic Protective Sexual Behaviour Misalignment between sexual scripts decreases prophylactic condom use This research has identified that misalignment between psychosocial sexual scripts decreases prophylactic condom use in heterosexual mature adults. It has already been established that script misalignment can cause anxiety and confusion during a sexual experience (Simon & Gagnon, 1984). It is proposed that when sexual scripts misalign either sexual partner may feel that the other is “not playing by the rules” (Wiederman, 2005). Through the identification of HMA sexual scripts and their mechanisms this research has been able to conceptualizes how script misalignment explains the navigation of prophylactic condom use; Condom used, Condom not used and Negotiation. As seen in Figure 24 Culture Scenarios make up the positioning of
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the behaviour. This positioning either supports or does not support the prophylactic use of a condom. Once this has been established, we then look at the interpersonal script to whether the individual’s past practice of condom use has been primarily a positive or negative experience. Finally, we then look at the interpersonal script for the purpose of the individual having the sexual activity and whether prophylactic condom use either inhibits or distorts said purpose. When the three scripts align (quadrant 1) a condom is used. Conversely when the three scripts do not align (quadrant 8) a condom is not used.
Figure 24. Sexual Script Alignment and HMA Prophylactic Sexual Behaviour
Positioning
Positioning Does NOT Support Positioning Supports Condom Use Condom Use Past practice of Past practice of Past practice of Past practice of Practice condom use is condom use is condom use is condom use is POSITIVE NEGATIVE POSITIVE NEGATIVE 1 2 3 4 Condom Used Negotiation Condom Used Condom NOT Using a Used condom does not inhibit or distorts the purpose of sex
5 6 7 8 Purpose Using a Negotiation Condom NOT Condom NOT Condom NOT condom inhibits Used Used Used or distorts the purpose of sex
Condom Condom Not Condom Positioning Practice Purpose
Used Used Negotiated*
KEY
* Use of condom is determined by the dominant sexual partner.
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Participants identified that the most important script in explaining prophylactic condom use was the intrapsychic script which has been established as the purpose for having sex. Thus, if a condom inhibits or distorts the purpose of having sex then condom use will not occur (quadrants 6, 7 & 8). This is supported by the sexuality literature whereby intimacy and connection are identified as the most important aspects of engaging in sexual activity (Kaplan, 1990; Messelis, Kazer, & Gelmetti, 2019). Thus, for condom use to occur two elements need to align positively with one of these elements being the purpose (quadrants 1 & 3). It is for this reason that a condom is not used in quadrant 4 as while the purpose is positive the positioning and practice are negative. The outcome identified form script alignment was negotiation (quadrants 2 & 5). Negotiation of condom use is likely to occur when the positioning and purpose facilitate condom use but the individual has had bad experiences with the practice. Similarly, when the positioning and practice of condom use have been positive, but the individual perceives that the condom will inhibit or distort the purpose of having sex then they are more likely to negotiate. The outcome of this negotiation is dependent upon which individual has dominance/power (crown) with the relationship. This is explained by the enactment of gender roles and is discussed in the following section. This research has demonstrated that the misalignment of scripts decreases prophylactic condom use and aids in the understanding of how HMAs navigate protective sexual behaviour.
4.4.6 The Role-Reversal of Gendered Power in Sexual Relationships The second theme identified regarding psychosocial scripting and HMA prophylactic protective sexual behaviours was the role-reversal of power. Past research and discussion have demonstrated that traditionally women are gatekeepers and consent to the sexual activity after being pursued by the male aggressor who then dominate (Broaddus et al., 2010; Carpenter et al., 2006). The enactment of the traditional gendered scripts was present within this research however, there was evidence of role-reversals. The first example of this was where the female has become the aggressor and actively pursues the male. While some men like this:
“I love super intelligent, career-based women. I like women who, who are actually in control..., I'm not one of those ones where women have to be more subservient. I like powerful women. I've spent my whole life around powerful
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women find the challenge being with a woman who doesn't really need to be with me..” Albert, 59
Others found the reversal as confronting and if the male would not consent (to not using a condom) the female would move onto another male:
“I've been approached so many times by women, fairly highly educated women too, I might add, in a good demographic, but [they] have said, 'no, it's fine, don't worry about it,' and I've said, 'uh, no,' and then they go, 'OK, well if you wanna do it, see ya.' It's like, whoa” Keith,55
Finally, some male participants found the reversal scary comparing the dating scene to a meat market and women as predatory:
“These meet up groups, the social events where there are a lot of predatory women gets very aggressive. It's ... It's not nice, though. I had to do a runner”. Liam, 56
One possible explanation for this is that women only want men for sex. Female participants expressed the desire to remain independent and not look after someone else:
“I am very independent…I don’t want to look after anyone.” Quinn, 61
“I don't want to smell morning breath. I don't want to, you know, I don't want to listen to them on the toilet. If I do ever shack up it'll be separate bedrooms, and we'll have a third bedroom that we meet up with for sex yet or just the kitchen.” Nellie, 51
The second role-reversal evident was one where males as gatekeeps are insisting upon condom use before consenting to the sexual activity:
“My ex-partner, that I hook up with occasionally, I call him the Condom King. We've always used condoms. Always. And now, particularly, meeting up at different times in different years, I've been seeing him on and off for 20 years, and we always use them.”Dorothy, 51
While this scenario was less prominent than increasing female aggressors’, changes in traditional gendered models need to be considered when designing interventions to increase HMA prophylactic protective sexual behaviours.
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4.5 How do HMAs perceive the lived experience of condom use and how does this co-create value?
To answer RQ2, participants were presented with two projective bubble drawings (Chapter 3-Figure 11 & 12). Building upon the semi structured interviews the activity aimed to explore the experiential elements of HMAs sexual encounters. Gentile et al. (2007) six component customer experience framework was used to explore these elements: sensorial, emotional, relational, pragmatic, cognitive and lifestyle. The first step of this research was to identify the elements of customer experience that were present for HMAs sexual encounters without a condom. The culmination of the CX elements of sex without a condom is illustrated in Figure 25.
Figure 25. The Customer Experience of Mature Sex
This data was elicited using the bubble drawing projective technique and an example of both a male and female participant map is presented in Figure 26 and Figure 27. Analysis of the bubble drawings identified that the emotional element of customer experience transcended all aspects of the sexual activity. It should also be noted that most of the participants vocalise positive sensorial elements of the sexual behaviour rather than project them onto the map.
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Figure 26. Male Participant’s Experience of Sex
Figure 27. Female Participant’s Experience of Sex
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4.5.1 The Mature Customer Experience of Sex The CX of sex without a condom is vital to the understanding of prophylactic condom use as this is the experience that all others are compared to. This research has found that the customer experience of mature sex is one that creates value for the HMA by satisfying their sensorial, emotional and relational needs. Not using a condom also reduces the complexity of the shared experience as it requires limited cognitive and pragmatic effort stemming from years of habitual behaviour. It was also established that sex without a condom embodied the lifestyle value of trust and intimacy for participants. The following sections discusses each of the CX elements with data excerpts. This is then followed by the customer experience of condom use.
Sensorial The sensorial elements of mature sex were positive for all participants and described as pleasurable, warm and passionate.
“I dunno if you've ever had natural sex but it is really fantastic [Interviewer
laughs] and it actually...the sensation gets delivered much quicker.” Albert, 59
“I said, I've got this theory where part of women like not using a condom where I think it's a primal urge for the seed, because I actually said that I enjoy you when you come inside me. I actually want you to come inside me.” Dorothy, 51
Emotional
Positive emotional elements were expressed by both male and female participants. Happiness, fulfilment and contentment were all associated with sexual experiences not using a condom. Negative emotional elements included feeling nervous and scared however these were more akin to thrill rides and horror movies whereby these elements are part of the excitement of the experience.
“OK, I'm feeling nervous, but that's also anticipation, excitement,” Dorothy, 51
Vulnerable and Embarrassed were identified as truly negative affects with feeling about body image being the primary concern (Figure 28):
“Well, I've got this image about my body. You know? I'm embarrassed for my body. One of them said that to me too. He was embarrassed, because I went, oh, if I get undressed I might just turn off the light, and I said, 'I don't want you to
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see my body because I'm embraced,' and he said, 'so am I!' and I said, 'OK.' Because they've got a pot belly, and we've got a little bit of scaring.” Celia, 57
Figure 28. Emotional Element- Embarrassment
Relational
Both male and female participants also referred to the relational element of sexual experiences with males using the term “connection” and female stating “intimacy”. It is also in this element that we see a difference between males and females. While males expressed beliefs around romance and the progression of the relationship. Females were more sceptical with some believing that males will; always put their own pleasure first, will say anything to get them into bed, are cheaters and liars and ultimately will settle as they want someone to look after them in their old age.
“I think men settle. Jerry's* already admitted to me that he's settled with his wife because he thought he wasn't going to meet anyone. My dad has already said, you know, he split up with my mum to be with this Asian woman who yells and screams and carries on with him, and it's the same. He's got this pattern of this women but he doesn't want to leave her because he doesn't want to be on his own.” Dorothy, 51 *name changed to preserve anonymity
“I just knew from my ex husband, that he really couldn't stay on his own and after we got divorced he asked me many times to go back to come back together. And very quickly I remind him of why we did the divorce and he very quickly
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found someone, cause he was more not independent, but for me it was much more convenient to be in a relationship.” Quinn 61
Pragmatic The pragmatic element was demonstrated through all the actions associated with the sexual act including the messy clean-up post coitus. The concept of “seamlessness” and timing were also discussed as benefits of having sex without a condom. The ability to transition from foreplay to penetration without stopping was key to differentiating sex with and without a condom.
“It's just straight in there. So, yeah, from oral sex straight into normal sex. It's seamless” Keith, 55
One female participant also identified that “not making a fuss” was a pragmatic element of the sexual experience (Figure 29). She expressed that in her sexual relationships she could not bring up her needs or wants as men had the power.
“It's difficult for me to have a conversation because I think they have more power but they're so silly because I'm very independent…. “Gwendolyn, 61
Figure 29. Pragmatic Element- Female Not Making a Fuss
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Cognitive The cognitive element was present with men worried about timing, mood and the act itself (Figure 30). Women on the other hand were more concerned about STIs and would try and rationalise not using a condom (Figure31).
Figure 30. Cognitive Element- Excerpt from Figure 26
Figure 31. Cognitive Element- Excerpt from Figure 27
Lifestyle Finally, the lifestyle element demonstrated that males and females both value trust, honesty and intimacy and that sex without a condom is the physical expression of these values.
“Yeah, and I don't know what it is. There are three little things I look for when I meet someone, whether they look you in the eye when they talk to you, their morals, you sort of understand after a few conversations how they think.” Wilhelmina, 57 “Yeah that's right, your looking for what do you call it (laugh) your looking for, your looking for the connection, where your feeling everything…… and you don't feel it with the condom on and that makes a difference I think” Monty, 64
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“He fulfils a need in me, now, like that intimacy and closeness.” Dorothy, 51
Once the CX of sex without a condom was established the CX of condom use was then explored. Following this a comparative analysis was conducted to identify how the CE elements either motivated or became a barrier to prophylactic condom use. All CE elements were found to be a barrier to condom use with only four also acting as motivators. The purpose of this section is to illustrate how the customer experience of condom use facilitates or inhibits prophylactic protective sexual behaviour. This will be followed by a discussion of the shared experience and anti-experience created by condom use.
4.5.2 The Mature Customer Experience of Condom Use The mature CX of condom use by participants is a complex dance between the competing needs of the individual and the shared sexual experience of the couple. Comparative analysis and discussion with participants identified that the CX of condom use is one that is lesser or considered to be “bad” in comparison to sex without a condom. Positive emotional affects were still part of the CX however these emotions were related to having sex rather than the condom itself. It was also identified that when exploring the sensorial CX elements participants were more vocal and comfortable projecting these elements onto the bubble drawing (Figure 32).
Figure 32. The Mature Customer Experience of Condom Us
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This data was elicited using the bubble drawing projective technique and an example of both a male and female participant map is presented in Figure 33 and Figure 34.
Figure 33. Male Participant’s Customer Experience of Condom Use
Figure 34. Female Participant’s Customer Experience of Condom Use
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Sensorial, Emotional and Relational While participants expressed that condom-less sex is the preferred experience males were more averse to condom use than females. This again appears to be the result of male participants focusing on the sensorial elements of the experience. Males attribute poor sensation, no enjoyment, uncomfortable friction and heat to condom use.
“It’s going to be bad sex because I've already got a doubt with Impotency so that's only going to heighten all the doubt I have.” Monty, 64
“the condom is limiting my enjoyment of the actual act”. M19
These negative sensorial elements inhibited and or distorted the desired sexual experience and resulted in negative emotional elements towards condom use. Females on the other expressed that while using a condom sensorially did not feel the same this did not result in negative emotions but rather a sense of relief.
“In some ways that could be quite respectful...that relief it sort of like erm, a confirmation that you're on the same page... “Florence 61
Both males and females stated that condom use relational wise implied that there is no relationship and the experience is for sex only. This also supports the emphasis on sensorial elements as paradoxically the casual sex is for sexual release and physical sensation. Using a condom also implied that there is a lack of trust and that the partner wanting to use a condom is insecure in the relationship.
Pragmatic, Cognitive and Lifestyle The pragmatic elements for males and females were similar where both imply ambiguity in who brings and proposes condom use and if they do have one is it in date.
“My partner actually said, are we going to have unprotected sex, and I said no, and then there was a bit of an awkward moment because I did indeed have a condom, but it was out of date (laughs)” Stanley, 50
Males also stated that they experience pragmatic issues regarding performance with condom use inhibiting their erection or distorting sensitivity which uncomfortably prolongs erection.
“I have had it. You can be frustrated, because sometimes the erection can fade away, and that was a first-hand experience for me.”Keith, 55
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“They um, they elongate the whole process. For me, having a condom on, takes me more time to have... 'Coz…the sensitivity's reduced.” Albert. 59
Cognitive elements for condom use were executed through problem-solving to cease future use. While both males and females stated that a one-night stand or first sexual encounter should use a condom ultimately, condoms are used until risk free status can be proved.
“Have you been tested lately?'….. I'll get a test done no problems.” Keith, 55
Finally, lifestyle elements again differed for males and females. As previously discussed males believed that condom use took the meaning out of having sex and thus would always equal bad sex. Females echoed these statements but also believed that men are generally after a good feed, sex and someone to look after them. Funnily enough both male and female s believed that use of a condom created doubt within the sexual relationship.
So, I just said to her, 'look, it's a safety thing and I don't know you. I don't really know you. I mean, I know you, what I see and what I know of you, but I don't know who you've slept with.' If you bring that up, that just ruins the night, then you're asking them, 'who have you slept with or whatever.' Ulrich, 57
“because she's not feeling secure. Or there is a non-secu, insecure one there? Emm.. Okay I tell you what I would do. I would put nervous... Insecure... Insecure erm in relationship...” Florence 61
The following section will discuss how the elements of customer experience can either motivate or form a barrier to HMA prophylactic condom use.
4.5.3 Customer Experience Motivators and Barrier of Protective Sexual Behaviour Though the exploration of CE elements of sex with and without a condom this research has been able to identify the mechanisms of CE that motivate or form a barrier to prophylactic condom use. All six elements were found to be barriers with only five of the six also working as potential motivators. Figure 30 illustrates the duality of these elements (excluding emotional). The emotional element was found to be only a barrier to condom use. Participants did not express positive emotions towards condom use either through discussion or psychoanalytic drawings. As previously discussed, the purpose of sex for HMAs is desire, connection and gratification all which condom use
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forms a physical barrier to. Thus, it is easy to see how only negative emotions can stem from their use.
Figure 35. Experiential Mechanisms of Prophylactic Condom Use
The CE experiential mechanisms of prophylactic condom use were identified as the 6 A’s: autonomy, alignment, acuity, affect, attitude, and assumption. The CX motivators of prophylactic condom use were identified as the 5 P’s: practice, play, perception, partner and post-coitus. Table 15 outlines the alignment between the mechanism, CX element, application and provides evidence via participants quotes.
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Table 15. Customer Experience Motivators and Barriers of Prophylactic Condom Use
CX Mechanism Element Application Evidence The inability of the “I just stopped and think about what you're condom to be used doing... It interrupts.” Florence, 61 seamlessly within the Autonomy Pragmatic “It does interrupt the flow. So it can be a bit sexual experience. awkward I suppose. Id much rather not”Monty, 64
The social norms around I know this sounds awful, but these women that are condom use & the around me that are so promiscuous has made me a Alignment Relational connection made between little bit more relaxed about things as well. You the individual, relationship know? Dorothy,51 type & perceived need. The insight to recognize “I don't consider I’m at risk.” Harold, 66
the potential risk (severity Acuity Cognitive & susceptibility) of “I'm not really worried about HIV and AIDS…. contracting an STI. Syphilis is very very uncommon.” Nellie, 51 Affect that using a Barriers condom has on the sexual “I hated it. The first experience, yeah, I just Affect Emotional experience. thought, 'I don't like this at all.' “Liam,56
Attitude towards condom “I find them very irritating. I've got like chemical use developed from past sensitivity and they cause friction burns on me. Attitude Sensorial sensorial experiences of Nellie, 51 use. “I've been really bad about not using condoms because I hate them” Liam, 56 Assumptions made about “I expect them to be honest with me, as I'm honest a sexual partners with them.” Vivian, 54 Assumption Lifestyle trustworthiness, cleanliness and truth in “There's some sort of implicit trust” Harold, 66 risk free status. The skills acquired from “It totally depend on the skills and capabilities of Practice Lifestyle knowledge and use of both the lady and the man”. Ralph, 59 product. Use of a condom in a fun “To be frank, the only reason we used it is for the Play Sensorial or novel way to enhance novelty” Xavier, 59 the experience. Awareness of potential “I'd have to be at risk of contracting HIV or AIDS
Perception Cognitive risks, severity & if I didn't know someone very well”.Wilhemina,57, susceptibility. Partner (first time and “a one night stand, I certainly you know have had casuals) increases condom experience at that, I would, this is slightly Partner Relational use. embarrassing, I would have to be pretty drunk not Motivators to be aware enough to use a condom.” Stanley, 50 Post-coitus can be very “I know one thing I do like about condoms, and messy and condom use that is a condom is instant cleanliness. You do not can reduce this making have a woman dripping seamen out of them. You Post-coitus Pragmatic resolution cleaner. don't have to worry about going and getting a towel. I can take it off, tie a knot, have a quick brush down and it's done, you can have a nice cuddle ...” Keith, 55
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The identification of CE elements as barriers and motivators to prophylactic condom use also established that these elements formed the process and outcome of the protective sexual behaviour. Cognitive, Pragmatic and Lifestyle elements of the CXF were identified as the processes of prophylactic protective sexual behaviour (Figure 36). If the process of condom negotiation, application, use and removal needs to be a seamless otherwise condom use will not occur. Any interruption to the natural follow of the sexual experience could result in the abandonment of behaviour.
Figure 36. Process of Condom use
The Emotional, Sensorial and Relational elements the of CXF were identified as the goal (outcome) of the sexual behaviour (Figure 37). As discussed in the previous sections on sexual scripting the purpose is the most importation element in navigating HMA sexual behaviour. Thus, if using a condom inhibits the goal than future use is unlikely.
Figure 37. Outcome of Condom use
This research offers new insights on behaviour and the experience of protective products and will aid development of more effective and efficient interventions to increase HMA prophylactic condom use. Understanding the customer experience
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elements of condom use aids both social marketing benchmark criteria (customer orientation, insight, exchange and competition) and WHOs operational approach to sexual health (pre-existing factors, guiding principles and intervention strategies) (French & Blair-Stevens, 2006; WHO, 2017a). The following sections will discuss the two other themes that emerged from the data: the shared experience and the anti- experience.
4.5.4 The Shared Experience The shared experience has been a common term used throughout this research. While the group consumption of services has been explored in the literature the shared experience of a single product and the anticipated outcomes this creates has yet to be explored (Johnston & Kong, 2011; Palmer, 2010). The shared experience was made apparent through discussion and projective bubble drawings.
“You know, it can be a very intimate experience with your partner… because it's a dual act...” Xavier, 59
Participants naturally referred to their sexual experience as “shared” involving themselves and their partner (Figures 38 and Figure 39). The projective technique captured physical evidence of the “shared experience”. Participants would draw of lines, arrows and place emotions and comments between the figures.
Figure 38. Evidence of Shared Experience of Condom Use
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Figure 39. Evidence of the Shared Experience of Condom use
This research has identified that when two customers simultaneously consume a single product the customer experience is created in three ways. As demonstrated in Figure 40 each HMA has their own customer experience of the condom during the sexual activity and as it is being used by both sexual partners simultaneously creates a third “shared experience”. Participants identified shared emotional (embarrassment, joy, optimism), physical (pleasure, pain, heat, friction) and practical (process, ambiguity, responsibility) aspects of condom use.
Figure 40. The Shared Experience of Condom Use
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4.5.5 The Anti-Experience: Condoms as a Paradoxical Product The final theme identified through this research was evidence of an Anti- experience. As identified in RQ1 the purpose of HMA sexual activity is desire, connection and gratification. Condoms are a physical barrier to this purpose and thus their use is contradictory. This was echoed in discussion with participants who illustrated that the experience of sex while using a condom was “not as good” as sex without a condom:
“I wouldn't want to do it…….it’s going to be bad sex” Monty, 64
“…. it's like missing the skin to skin contact.” Olive, 62
Participants were happy to be engaging in sexual activity and while using a condom was not the optimal experience, it was not considered to be the opposite of condom less sex. Rather the condom was seen to inhibit or distort elements of their anticipated experience. Figure 41 conceptualizes how this process occurs and explains HMA prophylactic protective sexual behavior.
Figure 41. The Anti-Experience of Condom Use
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The figure illustrates that the first component is the anticipated experience and objective of performing the sexual behaviour. The second component is use of the product (condom) by the consumer. This forms the next element which is the experience outcome. This experience will either match the anticipated experience (objective) or form an anti-experience. If product usage inhibits or distorts the experience in any way, then the experience objective is not achieved, and the anti- experience is formed. The individual’s evaluation of the anti-experience in comparison to the anticipated experience (objective) may then lead to discontinued use of the product and protective prophylactic sexual behaviour. Conversely if use of the product does not affect the anticipated experience (objective) then these experience match and continued use of the product and protective prophylactic sexual behaviour can be assumed. The theoretical and managerial implications of the anti-experiences are discussed further in Chapter 5 and future research recommendations for extensions of this concept are suggested.
4.6 Methodological Observations
Three key methodological observations were made apparent in the data collection phase of this research regarding sampling, the projective technique and the sensitive nature of the topic. Purposeful sampling using a criterion typology ensured that all participants identified as heterosexual, were mature (50 years or older) and sexually active. While this enabled exploration of the phenomenon those who participated were more open and willing to talk about sex. Despite this some participants still found discussing their current sex life as confronting and would often revert to their past sex life (youth) as this was more comfortable and socially acceptable. It was also observed that some participants struggled with the projective technique. While participants were happy to verbalize their responses and consented to being recorded, they did not want to physically write their responses onto to bubble drawing. Male participants especially struggled with this activity and when this became apparent the interviewer would offer to write the responses for them. Other participants enjoyed the whole interview and projective process and commented that it was both therapeutic and cathartic in nature. The final observation pertained to the sensitive nature of the topic. Some males did not want to embarrass or seem rude to the interviewer who was younger, Caucasian and female:
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“I'm not trying to be rude or I'm not trying to be...I'm not trying to be any way with you as a woman...” Albert, 59
“Ah, let's say, don't get offended because you're white woman ...” Jasper, 58
When these statements were made the participants were assured that the interviewer was objective and not offended and that their opinions and ideas were vital to the understanding of the phenomena.
4.7 Chapter Summary
This chapter has discussed the findings from the thematic analysis of the 24 semi structured interview with bubble drawings technique. Findings in response to the research questions pertaining to psychosocial sexual scripting and customer experience of prophylactic protective sexual behaviors have been examined. In Chapter 5, the theoretical and managerial implications of these findings will be discussed.
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5.1 Introduction
Sexual health continues to be a socially complex problem in Australia with sexually transmitted diseases causing significant burden of disease (AIHW, 2018). Heterosexual Mature Adults aged 50 years and older have been identified as an emerging vulnerable population with the true burden of STIs underestimated due to the many social and systemic barriers (Brooks et al., 2012a; Levy, 2002; Ogden et al., 2012; Zingmond et al., 2001). Heterosexual Mature Adults are the same people who were once young and it is unlikely that their sexual thoughts, fantasies, desires, abilities, and expressions have drastically changed (Messelis et al., 2019). Little is known about prophylactic protective sexual behaviours in mature consumer markets and how their past experiences influence their current behaviours. With the social and economic pressures of an aging population mature adult preventative health to the forefront of academic and practice (Kirkman et al., 2013). The social marketing and sexual health disciplines has identified that a holistic understanding of the lived sexual histories and the customer experiences of condom use needs to be explored. This thesis aims to understand the customer experience of heterosexual mature adult sexual activity and how they navigate protective sexual behaviours. Thus, this research addressed the following questions: RQ1: How do psychosocial scripts influence condom use behaviour by heterosexual mature adults? And RQ 2. How do HMAs perceive the lived experience of condom use and how does this co-create value? This chapter will discuss the findings from chapter 4 that addresses each of these questions, the theoretical and managerial contributions, limitations and future research agenda.
5.2 RQ1: How do psychosocial scripts influence condom use behaviour by heterosexual mature adults?
This research has identified that the psychosocial scripts of HMAs explain prophylactic protective sexual behaviour through the positioning (cultural scenarios) and practice (interpersonal scripts) of the behaviour which each able to motive or inhibit the prophylactic use of a condom. However as previously discussed in Chapter 4 the purpose (intrapsychic script) of having sex is the most important aspect in explaining prophylactic protective sexual behaviour. This means that while the
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positioning and practice may support prophylactic protective behaviour if this disrupts the purpose of sex then the behaviour may be abandoned. This is supported by the sexuality literature whereby intimacy and connection were seen to have the greatest impact on quality of life (DeLamater & Moorman, 2007).
The identification of the intrapsychic script (purpose of having sex) as the most influential differs from previous studies using sexual scripting where the three scripts are intertwined and are framed by culture scenarios (Hall, 1997; Van Gorp, 2006). Identification of the interpersonal script as a decisive influencer on HMA protective prophylactic sexual behaviour allowed for the recognition of when a condom would be used, not used or required negotiation. For condom use to occur a minimum of two of the sexual scripts needed to support condom use with one of them being the intrapsychic purpose. If the sexual scripts did not support the use of a condom then it was not used, and this was the most common scenario. Finally, when two scripts support the use of a condom the negotiation is required. The outcomes of this negotiation were dependent upon who has the power/dominance within the sexual relationship. The sexuality literature usually aligns this power with the female as she is the gatekeeper (Carpenter, 2010; Wiederman, 2005). Conversely this research has found that there has been a gender role reversal whereby males are the gatekeeper as females become more aggressive and dominant. This may be a result of females living longer and the scarcity of potential male partners (Henning-Smith, Gonzales, & Shippee, 2015; Kruger & Schlemmer, 2009). The preference of HMA males to seek younger partners also adds to the scarcity of potential male partners. Another explanation for female aggressors is the fact that they only want men for sex.
5.3 How do HMAs perceive the lived experience of condom use and how does this co-create value?
The purpose of RQ2 was to understand the customer experience of protective sexual products (condoms) and how these facilitate or inhibit HMA protective sexual behaviours. The framework used to understand the customer experience of condom use was Gentile et al. (2007) six component framework; sensorial, emotional, relational, pragmatic, cognitive and lifestyle. The framework proposes that good experiences involve a person across multiple dimensions and while the experience may be perceived as complex it is viewed holistically (Gentile et al., 2007). This aligns with both the social marketing and sexual health lenses. Participants identified all six
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elements as barriers to condom use; Attitude (sensorial), Affect (emotional), Alignment (relational), Autonomy (pragmatic), Acuity (cognitive) and Assumption (lifestyle). While only five were identified as motivators; Play (sensorial), Partner (relational), Post-coitus (pragmatic), Perceptions (cognitive) and Practise (Lifestyle). The emotional element of the customer experience of protective sexual products was only found to be a barrier as the use of a condom was found create negative emotional affect (Laros & Steenkamp, 2005). This is supported by the marketing and psychology literature where negative emotions can cause embarrassment, decrease confidence and result in poor self-concept (Agnew & Loving, 1998; Libbus, 1995). The research also established the presence of the shared experience and anti-experience. These concepts will be discussed in the following section as they are theoretical contributions.
5.4 Theoretical Contributions
This research has identified three contributions to customer experience theory. These contributions are the Misalignment of Process and Outcome, active involvement in the Shared Experience and the Anti-Experience.
5.4.1 Misalignment of process and outcome of the sexual experience decreases prophylactic protective sexual behaviours The identification of CX elements as motivators and barriers of prophylactic protective behaviours allowed for the operationalize of these elements into the process and outcome of the behaviour. As previously discussed CX literature is in its nascent stage thus this research adds valuable insight and contribution by conceptualising how CX elements explain behaviour (McColl-Kennedy et al., 2015). The elements cognitive, pragmatic and lifestyle represent the process of protective sexual behaviours. This encompasses the knowledge, skills and acuity to recognise risk and enact the protective behaviour processes. This includes sourcing, purchasing, storing, transporting, negotiating, using and deposing of the resource (condom) (Vargo et al., 2008). If at any stage of this process inhibits the outcome, then there is a misalignment and continued protective sexual behaviour is unlikely. Conversely if the CX processes are seamless or enhances the experiential outcome then prophylactic use of the resource is more likely.
Using sexual scripting this research identified the purpose of sexual activity for HMAs as desire, connection and gratification. This purpose forms the experiential
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objective of performing the behaviour. Thus, the CX elements of emotional, sensorial and relational represent the outcome (experiential objective) of the behaviour. Like the process if the use of a resource (condom) inhibits the outcome then there is a misalignment and prophylactic protective sexual behaviour is unlikely. However, if the use of the resource enhances the experience then prophylactic protective sexual behaviour is more likely to occur.
Figure 42 conceptualises this process and illustrates the CX elements of the process and outcome and how they have the power to both motivate or form a barrier to prophylactic protective sexual behaviour. It also shows that the process can enhance or diminish the outcome. The managerial implications from the misalignment of processes and outcomes of the customer experience for HMA prophylactic protective sexual behaviours are discussed in section 5.5.
Figure 42. Customer Experience of Protective Sexual behaviour: Process vs Outcome
Enhances Experience
Diminishes Experience
5.4.2 Active involvement in the shared experience facilitates protective sexual behaviours The public health literature has extensively studied protective behaviours in youth and homosexual consumer markets (Sheeran et al., 1999). The use of a social marketing lens and customer experience literature has identified the phenomenon of the Shared Sphere. The Shared Sphere occurs when a single service and or product is simultaneously used by two customers. This concept extends upon Grönroos and Voima’s (2013) value spheres. In their article Grönroos and Voima propose the value creation spheres; provider sphere, joint sphere and customer sphere (Grönroos and
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Voima, 2013). They state that the provider sphere produces resources and processes for the customer’s use and as such are value facilitators. The joint sphere is where there is direct interaction between the provider and customer (P2C) and in this space the provider and customer can co-create value both through said processes and resources. The rest of the customer sphere is closed to the provider whereby the customer creates value through independent value-in-use (Grönroos and Voima, 2013). This research proposes a second customer sphere (other customer) and when the two customers simultaneously engage in the use of a resource or process from a provider then the shared sphere is created. This has been conceptualised in Figure 43 extending Grönroos and Voima’s (2013) value spheres.
Figure 43. The Shared Sphere
Joint Sphere Shared Sphere (Provider to Customer P2C) (Customer to Customer C2C)
Other Provider Customer Customer Sphere Sphere Sphere
(Grönroos and Voima, 2013) This Research
Central to S-D logic is the proposition that the customer becomes a co-creator of value (Vargo & Lusch, 2008). The literature traditionally views this as the co-creation of value between the provider and customer (Verhoef et al., 2009). The shared consumption of processes and resources between customers can also result in the co- creation of value. It is proposed that a simultaneous exchange occurs between both the customers and each customer and the process/resource. Like the first customer sphere the Shared Sphere and Other Customer Sphere is independent from the providers visibility and control (Grönroos and Voima, 2013). This was seen in protective sexual
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behaviours as when each customer actively participated in the eroticization of the process of using of the resource (condom) then it was more likely to be used and enjoyed. Value was co-created through the experience of use as both sexual partners were beneficiaries. This is supported by the sexual health literature that has documented that interventions that eroticize protective behaviours saw improved sexual risk outcomes (Scott-Sheldon & Johnson, 2006). The managerial implications of the Shared Sphere for HMA prophylactic protective sexual behaviours are discussed in section 5.5.
5.4.3 The Anti-Experience: products and services that inhibit or distort the experiential objective
This research facilitated a deeper understanding of the customer experience and identified the Anti-Experience. Much like Doctor Who’s alternate dimensions and Virginia Woolf’s reflections in the looking glass the potential interpretation of an experience is multifaceted due to the complex and interpersonal nature. This research has identified that an Anti-Experience occurs when one or more of the experiential elements (sensorial, emotional, relational, pragmatic, cognitive, lifestyle) inhibits or distorts the experiential objective.
To unpack this concept, we start with the “typical” customer experience process (Figure 5.3). The CE process begins with the experiential objective which is the thing aimed at or sought after; the goal of and reason for having the experience. Theoretically this is the satisfaction of a hedonic need (Childers, Carr, Peck, & Carson, 2001). When a customer seeks to meet this need, they engage in a service and by extension of S-D logic a product (Vargo & Lusch, 2008). The customer already has a preconceived idea of what the experiential elements will be, and this is the anticipated experiential outcome. If the consumption of the product/services experiential elements fulfil the experiential objective than the anticipated experience is achieved. This process has been conceptualised in Figure 44.
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Figure 44. The Customer Experience Process
Experiential Product/ Anticipated
Objective Service Experience
The Anti-Experience is an alternate explanation of the customer experience process. Much like a prism the interpretation of the customer experience from the consumption of a product or service can be refracted. It is proposed that this occurs when any of the experiential elements inhibit the experiential objective through the prevention, reduction of impediment of the anticipated experiential outcome. Equally, if any of the experiential elements distort the experiential objective by pulling or twisting the anticipated experiential outcome out of shape than an Anti-Experience occurs. This process has been conceptualised in Figure 45.
Figure 45. The Anti-Experience
Anti- Experiential Experience Objective
Experiential Customers Consumption Element/s Experiential Hedonic of Product Inhibited or Outcome Need /Service Distorted
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The Anti-Experience is not the direct opposite of the anticipated or necessarily a bad experience but rather is an alternate interpretation. There may even be some instances where the Anti-Experience is better than the anticipated providing potential value propositions of the product and or service that are salient to the customer and or social marketer. The managerial applications of this for HMA prophylactic protective sexual behaviours are discussed in section 5.5.
5.5 Managerial Contributions
This research provides three managerial contributions for social marketers and sexual health practitioners to increase the prophylactic use of protective sexual products and reduce the increasing rates of STIs in heterosexual mature adults. These are redesigning product elements to overcome misalignment, create value propositions for the shared sphere and identification of anti-experiences and strategies. The following sections discuss the implications of these managerial contributions.
5.5.1 Redesigning Product Elements to Overcome Misalignment Misalignment was a strong theme within the data with the main misalignments were between the purpose for having sex (experiential objective) and the process (positioning and practice) of using the prophylactic protective product. Sexual activity is a natural and fundamental part of being human (Marshall, 2011). This research has identified that the problem with condom use lies with the product and the processes of its use. Thus, product elements need to be redesigned with mature consumers to make the processes of use more natural and seamless.
Packaging elements such as the box and its outer clear plastic and the chain of sealed foil packets containing the condom needs to be easier to open, perforate and remove. Mature consumers loose dexterity with age making the process of opening the box and packaging of the condom difficult (Carmeli, Patish, & Coleman, 2003). Like dexterity vision loss and lower functional ability makes it almost impossible to read the instructions currently provided with the product (Whitbourne, 2012). Physiological changes resulting in vaginal dryness is another area where the humble condom could be improved. These are some suggestions developed from discussion with mature consumers. Further research of the mature customer journey and pain points of using protective products need to be explored. Workshops where providers and mature
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consumer co-create, and redesign protective sexual products should also be considered.
5.5.2 Creating Value Propositions of the Shared Sphere This research has identified the Shared Sphere where simultaneous exchange occurs between two customers and the process/resource. The value created within the shared sphere is uniquely and phenomenologically determined by the beneficiaries of the shared experience and as individual customers (Grönroos & Voima, 2013). Akin to the first customer sphere, the Shared Sphere and Other Customer Sphere is independent from the provider’s visibility and control (McGraw, Russell-Bennett, & White, 2018). Active involvement by both customers with the resource/process (condom) in the shared sphere was found to facilitate behaviour. The shared sphere presents an opportunity for social marketers to create value propositions for mature consumers that focus specifically on enhancing, eroticizing and enriching the shared sexual experience of condom use. Mature consumers should be involved in this process as they are the reflective actors and the only actors who can elicit and articulate the value of condom use within the shared sphere (Gordon & Gurrieri, 2014; McHugh & Domegan, 2017). Barriers to condom use identified within the shared sphere included embarrassment, physical pain, heat and friction and process ambiguity. Social marketers could address these barriers by redesigning the packaging (easier to open, mature branding), product (ultrathin and extra lubrication) and instructions (larger print and application strategies) to ensure an erotic experience is feasible.
The shared sphere also presents an opportunity for social marketers, sexual health practitioners and providers of sexual health products to create value propositions that focus specifically on the shared experience. These propositions should primarily focus on how the shared use of protective products can enhance the both the shared and individual sexual experience. The experience elements of sensorial, emotional and relational (outcome) could be enhanced and by promoting strategies and tactics to increase intimacy and sexual sensitivity when using a condom and remove stigma around condoms use and casual sex. If no value propositions can be identified, then there is further justification for product redesign. We are moving into the experience age and as previously discussed new materials such as graphene, nanofabrics and hydrogels are still being tested. As these innovations are introduced
Discussion 125
to the market social marketers and sexual health practitioners should explore potential value propositions of the shared sphere.
5.5.3 Anticipating Anti-Experiences The Anti-Experience proposes that the customer experience is not polarized as good and bad but rather is multifaceted. Paradoxically customer experience elements can be distorted and or inhibited by the consumption of the product or service creating the experience. This was present in the research context of HMA protective sexual behaviours where the use of a condom inhibited and or distorted elements of the customer experience. The experiential objective of HMA sexual activity was identified as desire, connection and gratification. Table 16 summarises potential social marketing strategies to overcome Anti-Experiences identified by participants that decrease HMA condom use.
Table 16. Anti-Experiences Strategies for HMA Prophylactic Condom Use
Experiential Experiential Anticipated Condom SM Strategy Objective Element Anti- Experiences Decreased sensitivity, Redesign product to overcome physiological loss of erection changes- thinner, new materials, gels or Sensorial chemicals to stimulate arousal or orgasm.
Friction and heat. Extra lubrication on condom or included in packaging Positive-peaceful and Promote positive emotions and value of relived. condom use- peace, relief and respect Emotional Negative- angry, Skills and strategies to create intimacy and frustrated, not happy, fulfilling experiences with condoms. discontented, unfulfilled Just sex, one-night Reposition condoms to reduce product Relational stand, hook ups associations with casual sex. Hard to open box and Redesign box packaging with tab for easy foil packet plastic removal (e.g. gum tabs) and larger v segments in foil for tearing.
Pragmatic Awkward Discussion Negotiation, erotizing and application game instructions included in box (in large print). Sizing Rebrand boxes to have “positive” sizing guides on back. Low risk perceptions Promotions to increases HMA acuity of Desire, Connection & Gratification Desire,Connection Cognitive transmission and risk. Product choice Rebrand packaging and promotions to align Lifestyle with HMA values, body image and attitudes.
126 Discussion
5.6 Research Limitations and future research
This research had limitations regarding the qualitative methodology and sensitive nature of the topic. This section will examine these limitations and propose a future research agenda. A qualitative methodology was deemed as the most appropriate for eliciting in-depth information the trade-off was a small sample size. This means that while findings are insightful and offer in-depth understanding of the phenomenon, they are not representative of all heterosexual mature adults. Purposeful sampling ensured that the phenomenon was present within the participants however those who volunteer to were more open in talking about sex. HMAs who are sexually active but are more conservative may not have been included within the sample. There may also be evidence of social desirability with participants potentially telling the interviewer what they wanted to hear and or what they thought was socially acceptable. Future research could look at how to quantify the concepts presented in this thesis and distributing this to a large sample to overcome these biases and identify the strength and relationships between elements. The second limitation identified was the one- sided interview. Sexual behaviour involves two or more people and thus further research should be conducted with couples to identify the customer journey of each sexual partner leading up to, during and after condom use to further refine pain points within each customer sphere and the shared sphere. The final limitation concerns the selection of a single context. Further research and application of the customer experience process and outcome model, shared sphere and Anti-Experience to other contexts, behaviours, products and services is needed.
5.7 Conclusion
This research has holistically explored the protective sexual behaviours of heterosexual mature adults aged 50 years and older. The examination of the lived experiences of HMAs and customer experience elements of prophylactic condom use has revealed the complex and shared nature of sexual behaviours. This research also provides approaches for social marketers and sexual health practitioners to address the increasing rates of STIs within mature consumers. These strategies illustrate that if condom use is to be increased within mature consumer markets the product, packaging and positioning needs to change to align with the physiological, cognitive and social changes of ageing.
Discussion 127
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Appendices
Appendix A- Sexually Transmitted Infections
Infection Transmission Symptoms Treatment Bacterial Vaginosis Not usually passed Common to not notice symptoms Antibiotics Increased vaginal discharge, Fish-like smell & Vaginal irritation Chlamydia Semen, Pre-ejaculate Common to not notice symptoms Antibiotics
Vaginal & Anal fluids Abnormal discharge &Pain or trouble urinating
Chancroid Skin-to-skin contact with Multiple, deep, painful genital ulcers Antibiotics open sore Bacteria Gonorrhoea Semen, Pre-ejaculate, Common to not notice symptoms Antibiotics Vaginal & Anal fluids Abnormal discharge Pain or trouble urinating Lymphogranuloma Semen ,Pre-ejaculate, Common to not notice symptoms Antibiotics Venereum Vaginal & Painless sores, Swollen lymph nodes & Anal fluids abscesses
Appendices 145
Mycoplasma Skin to skin, Semen Abnormal discharge, Pain, burning or stinging Antibiotics Genitalium Pre-ejaculate, Vaginal & when urinating &Pain during sex Anal fluids Pelvic Inflammatory Ascension of Pain in the lower abdomen, Pelvic pain Antibiotics Disease microorganisms from the Vaginal discharge, Abnormal uterine bleeding Surgery cervix & vagina to the Pain during intercourse, Fever and chills (females only) upper genital tract. Difficulty in urination Syphilis Skin-to-skin contact Common to not notice symptoms Antibiotics Painless sores & Non-itchy rash Genital Warts Skin-to-skin contact Painless bumps on the skin Topical medications Hepatitis A Faecal-oral contact Combination of nausea, loss of appetite, fever, Vaccination stomach pain, jaundice, dark urine, grey- coloured stool Hepatitis B Blood, Semen, Pre- Common to not notice symptoms Anti-viral ejaculate, Vaginal fluids Combination of nausea, loss of appetite, fever, medications stomach pain, and jaundice Vaccination Hepatitis C Blood Common to not notice symptoms Anti-viral Combination of nausea, loss of appetite, fever, medications
Virus stomach pain, and jaundice Herpes simplex Skin-to-skin contact Common to not notice symptoms Anti-viral virus Itching, burning, or tingling sensation, painful medications sores/ blisters Human Skin-to-skin contact Common to not notice symptoms Vaccination Papillomavirus Genital warts, Cancer Human Blood, Semen Common to not notice symptoms Anti-viral Immunodeficiency Pre-ejaculate, Vaginal & Flu-like illness; headache, muscle aches and medications Virus Anal fluids, Breast milk joint pain &swollen glands (seroconversion illness) Pubic Lice Genitasl and other body Genital itching & visible lice in and around pubic Topical hair hair medications
Scabies Skin-to-skin contact Itchiness (especially at night), Rash between Topical Sharing clothes, bedding fingers, on wrists, armpits, genitals, thighs medications & towels Parasites Trichomoniasis Semen, Pre-ejaculate, Common to not notice symptoms Antibiotics Vaginal fluids Abnormal vaginal discharge Pain or trouble when urinating Appendix B- Application of Context to SM Benchmark Criteria
146 Appendices
Definition Application to Thesis & HMA Condom Use Interventions need to focus on prophylactic condom use behaviour
in HMAs not just knowledge, attitudes and beliefs. There also needs to be clear specific, measurable and time-bound behavioral goals Aims to change people’s actual that has been set at base line and clearly identified key indicators for behavior. success. This research will help identify the current knowledge, Behaviour attitudes and beliefs of HMAs regarding condom use and develop realistic and achievable behavioral goals.
Involving HMAs in the research process to gain key insights to use Focuses on the audience and for future development of interventions to increase prophylactic understanding their lives, condom use. These insights should be collected using a range of behaviours and issues using a methods and data sources. This research will explore HMAs lived mix of data sources and
Customer Customer experiences and behaviours using a mix of qualitative techniques to Orientation methods. illicit data.
Use of behavioral theories to Research is guided by behavioural theories to understand HMAs understand behaviour and behaviours of condom use in casual sexual encounter. Validation or inform the intervention. emergence of new theories through customer orientation research Theory will be used to guide future inventions. Research will gain a deep understanding of what moves and Customer research identifies motivates HMAs including who and what influences condom use in ‘actionable insights’ – pieces of casual sexual encounters. Insights will help inform the customer understanding that will lead
Insight orientation and develop an attractive exchange to encourage intervention development condom use. Considers benefits and costs of Research will explore perceived/actual costs and benefits of HMA adopting and maintaining a new condom use in casual sexual encounters. This will help identify what behaviour; maximises the HMAs value and how this in turn can be used to inform and leverage benefits and minimises the the exchange to encourage condom use.
Exchange costs to create an attractive
offer
Research will identify the direct and external factors that compete
Seeks to understand what with HMA condom use behaviour. This will help develop strategies competes for the audience’s to minimise this competition. time, attention, and inclination to behave.
Competition
Avoids a ‘one size fits all’ Research will help identify segments within the HMA market. approach: identifies audience Drawing on behavioural and psychological data segments can then ‘segments’, which have be priorities and interventions can be tailored. common characteristics, then
tailors’ interventions
Segmentation appropriately
Elements of the marketing mix (product, price, place and promotion)
Uses a mix of methods to bring and the intervention method will be explored. Analysis of existing about behaviour change. Does interventions will be considered in order to avoid duplication. This
Mix not rely solely on raising will help identify the need for a new brand or the leveraging of Methods Methods awareness existing brands to enable behavioural change of HMAs. Appendix C- Application of Context to Ottawa Charter
Appendices 147
Charter Definition Application to Actions need to be aimed at Acknowledgement that HMA making political, economic, social, sexual health is important and cultural, environmental, advocating for the political, Advocate behavioural and biological factors economic, social and cultural conditions favourable through environments to support advocacy for health. healthy sexual behaviours.
Achieving equity in health through Crating equal opportunities for all
actions aimed at reducing differences HMAs to access resources and in current health status and creating services to achieve sexual health. Enable
Strategy equal opportunity and resources to enable people to achieve their fullest health potential. A coordinated action from Working across and with different government, health and other social disciplines and organisations to Mediate and economic sectors to mediate promote and facilitate HMA between differing interests in the sexual health. pursuit of health. Supporting personal and social Activities that helps HMAs learn development through providing about STIs, condom negotiation Developing Personal information, education and enhancing and correct condom use and Skills life skills to make choices conducive disposal. to health. Reciprocal maintenance to take care Creating environments that of each other, our communities and support HMA sexuality and Creating Supportive our natural environment to generate sexual health. This will involve Environments living and working conditions that are overcoming ageist attitudes both safe, stimulating, satisfying and publicly and within the health enjoyable. services sector.
Fostering ownership and control Fostering a sense of to strengthen public participation ownership within HMAs in Strengthening Community in and direction of health matters. regard to their sexual health, Action the services offered and
Action AreaAction support within the community. Health research and changes of Providing sexual health services attitude and organisation of health and products outside of Reorienting Health services that refocuses on the total conventional settings or services. Services needs of the individual as a whole person. Combines diverse but Developing policies and complementary approaches guidelines that facilitate Building Healthy Public including legislation, fiscal healthy sexuality across the Policy measures, taxation and life course of individuals. organizational change that fosters greater equity
Appendix D- Media Release
148 Appendices
Back on the market: Understanding condom use in the over 50’s Sexually transmitted diseases are on the rise in the over-50 age group and, in fact, could surpass the infection rates of younger people, says a QUT researcher investigating the low use of condoms in this age group. QUT social marketing Masters student Natalie Bowring, from QUT Business School said emerging trends suggested the incidence of sexually transmitted infections (STIs) in older adults, 50- plus, has doubled between 2004-2010, with sexually active older Australians contracting chlamydia and gonorrhoea in rapidly increasing numbers. Ms Bowring is hoping to interview heterosexual people aged 50 years or older, who have been sexually active within the last 12 months on their beliefs and attitudes towards condoms with the aim of better understanding the barriers and motivators of unprotected sex. She is also interested in speaking to condom manufactures and marketers about the development of condoms for the more “experienced” older adult market. While ageist attitudes would have us believe that older adults magically become asexual, this is clearly not the case, Ms Bowring said. “With life events leaving many older adults divorced or widowed and multiple platforms such as internet dating and international travel, more and more older adults are increasingly ‘back on the market’ and actively seeking sexual relationships.” “Using a condom could prevent STIs but this age group tends to see condoms in terms of contraception rather than a form of protection, as older adults began their sexual lives in a time of unprecedented sexual freedom thanks to the pill and the women’s liberation movement,” Ms Bowring said. “The rising rate of infection indicates older heterosexual adults are engaging in frequent, risky sexual behaviour but very little research has been done on why they are not using condoms or how to encourage their use in this age group. “In the UK, which has a similar STI increase, they have tackled this situation with the Middle-age Spread campaign which focuses on condoms improve over 50s’ sexual health. Ms Bowring would like conduct face to face interview with participants who volunteer for the study. To contact her to take part in the study, [email protected]
Appendix E- Q&A Participant Screener
Appendices 149
Good ______, I am calling from Q&A Market Research in Milton; we are organizing some in-depth one-on-one interviews that you may be eligible for, may I ask you some questions to see if we can ask you to come along…?
Q1. Do you or any members of your immediate family or close friends work or are involved in any of the following industries? (Please select all that apply.) [READ OUT – MULTIPLE RESPONSE]
1. Market Research TERMINATE 2. Media TERMINATE 3. Marketing TERMINATE 4. Advertising TERMINATE 5. Public relations TERMINATE 6. Health-related industry TERMINATE IF DOCTOR, NURSE ETC. OR INVOLVED IN SEXUAL HEALTH 7. None of the above CONTINUE
Q2. Have you attended a market research focus group discussion or interview in the past 6 months, or are you booked in to attend one in the near future? [READ OUT – SINGLE RESPONSE]
1. Yes TERMINATE 2. No CONTINUE Q3. Please record your gender. [DO NOT READ OUT – SINGLE RESPONSE]
1. Female CONTINUE 2. Male TERMINATE Q4. What is your age category? [READ OUT – SINGLE RESPONSE]
1. Under 18 TERMINATE 2. 18-50 TERMINATE 3. 50-59 CONTINUE 4. 60-70 years CONTINUE 5. Over 70 years TERMINATE
Q5. Which of the following best describes your sexual orientation? [READ OUT – SINGLE RESPONSE]
1. Heterosexual CONTINUE 2. Homosexual TERMINATE 3. Bisexual TERMINATE 4. Asexual TERMINATE
150 Appendices
5. Other (please specify) TERMINATE
Q6. Are you currently in a long-term/committed relationship? [READ OUT – SINGLE RESPONSE]
1. Yes TERMINATE 2. No CONTINUE
Q7. Are you currently sexually active? [READ OUT – SINGLE RESPONSE]
1. Yes CONTINUE 2. No TERMINATE 3. Your participation will involve an audio recorded interview at QUT gardens point Questions will include: • What is your opinion on condoms? • Have you ever used them? • Who is/was the main influencer in your decision to use or not use a condom? • What do you think men and women think, fell and expect from sex with/without a condom?
All comments and responses will be treated confidentially unless required by law. This project will involve audio recording and as such you will have the opportunity to verify your comments and responses prior to final inclusion. Any data collected as part of this project will be stored securely as per QUT’s Management of research data policy.
Are you still interested in attending an in-depth one-on-one interview?
CODE RESPONSE ACTION 1 Yes CONTINUE 2 No TERMINATE
Respondents name………………………………………………time & date of group………………
Ph nos [h]…………………………………[w]……………………………[mob]…………………………
EMAIL ADDRESS FOR EVERYONE ………………………………………………………………………….
Recruiters name………………………………………………date…………………………..
Appendix F- Interview Guide
Appendices 151
152 Appendices
Appendices 153
Appendix G- Emotion Stickers
154 Appendices
Appendix H - Sample Code Book
Gap 1. We do not know the beliefs and attitudes related to condom use by heterosexual mature adults and how they navigate protective sexual behaviours. RQ 1. How do psychosocial scripts influence condom use behaviour by heterosexual mature adults? Sexual Scripting (Simon and Ganon 1986) Definition from literature Application Words Quote The instructional guides that Persons learn about life Age, gender, social Yeah its pretty much exist at the level of collective by being given directions class, education, dates, considered my life. The instructions for roles about how to act that are expectations, rules, responsibility. They don't are embedded in narratives embedded in stories with religion, date, meeting, even ask; I mean not even (the scripts for the specific good outcomes and bad health, pregnancy, when I was still fertile.”
role) and they provide the outcomes (such stories menopause, sexuality, F14 understandings that make identify what is to be erectile dysfunction,
role entry, performance and done [or not done], where affair, marriage, divorce. Gonorrhea was a big thing script exit plausible. it is to be done, when it is those day, they advertise it to be done, with whom it on TV, it was awful…. Well is to be done, and why it it was a dribbly penis…… Cultural should be done). it was pretty scary stuff. M8
My ex-partner refused to wear a condom. He refused.F4 Operate at the level of social In this case the individual Male, female, boy, girl, If it was a new partner, interaction and the is an actor meeting the woman, man, expected, obviously I wouldn't know
acceptance and use of such expectations of other responsibility, first move, that straight away so it scripts are the basis for persons and guiding their sequence, order, would certainly be a case continued patterns of conduct in terms of the discussion, relationship. of dependent upon my structured social behavior. conduct of the other. partner, and how well I knew them.” M19
It just depends on the person as well, because if you have discussed Interpersonal Interpersonal scripts condoms with this person before, then there's no issue. M21
The ideal version of cultural Such scripts can range Arousal, pleasure, Intimate experience with scenario (how one ought to from the most orderly desire, want, connection, your partner… because it's behave) and the pragmatic cognitive narratives, orgasm, relief, a dual act... M24 variants are concurrently desires, memories and stimulation, fantasies, held in the mind of the plans sex, fuck, screw, It does interrupt the flow individual. M13.
Skin you know, like
you...it's like missing the Intrapsychic scripts scripts Intrapsychic skin to skin contact...” F15
Appendices 155
Gap 2. We do not know the lived customer experience elements of condom use by heterosexual mature consumers. R2. How do HMAs perceive the lived experience of condom use and how does this co-create value? Six Component Customer Experience Framework (Gentile et al, 2007) Component of the Can lead customer to Think, plan, create, important, problem, “Yeah, at least a month customer experience revise the usual idea of reason, reflect, propose, plot, make, and maybe a two before
connected with thinking a product or common produce, difficult, obstacle, challenge, stopping using or conscious mental mental assumptions perceive, consider, choose. [condoms].” F4 processes; an offering may engage customers Well, he didn't want to use Cognitive in using their creativity a condom either, so that's or in situations of why I had another problem solving. pregnancy F3 Component of the Can generate emotional Jealousy, Angry, Hostile, Envious, It can be actually be a bit customer experience experience in order to Scared, Frustrated, Envious, Nervous, more joyful. You know which involves one’s create an affective Unfulfilled, Irritated, Sad, Afraid, because there's been affective system relation with the Warm-hearted, Nostalgia, Worried, connection. F6 ional through the generation company, brand or Enthusiastic, Ashamed, Miserable, of moods feelings, products. Fulfilled, Guilty, Encouraged,
Emot emotion. Humiliated, Please, Peaceful, Thrilled, Hopeful, Sentimental, Joyful.
Component of the Aims to provide good See, view, look, appearance, smell, because you're feeling
customer experience sensorial experience- scent, fragrance, odor, sense, feel, nothing, you know? M10 whose simulation sight, hearing, touch, pleasure, feelings, touch, pain, arousal, affects the senses. taste, smell to arouse experience, handle, natural, unnatural, Yep, they hate it and they aesthetic pleasure, texture, sensation, sound, noise, mood. reckon it feels better
Sensorial Sensorial excitement, satisfaction without it. F4 and sense of beauty. Component of the Encourages the use or Partner, approval, consent, trust, Um, he was looking for customer experience consumption with support, agree, disapproval, company and he wasn't that involves the others, is the core of a displeasure, annoyance, irritation looking for a relationship person and their social common passion which disappointment, frustration. F3 context, relationships leads to the creation of If you where just going to with other people and community or tribe of sleep with someone, have their ideal self. fans or can be used as a one-night stand with
Relational a means of affirmation someone you've met at of a social identity. Kings Cross or up the Valley, there's a good chance you might get something.” M13 Component of the The pragmatic Packaging, use, get rid of, dispose, “You can be frustrated, customer experience components include the open, purchase, buy, price, features. because sometimes the coming from the concept of usability erection can fade away, practical act of doing across the entire and that was a first-hand
something. product lifecycle. experience for me”. M11 Pragmatic Pragmatic
156 Appendices
Component of the Product itself and its Value, believe, safe, protection, like, Well protecting...yes it is customer experience consumption or use don’t like, power, use, don’t’ use, but...and also protecting
that comes from the becomes means of religion, doctor, parents, friends, her...M24
affirmation of the adhesion to certain partner.
systems of values and values the company “It can be looked at as festyle
Li beliefs of the person and brand embody and being respectful and often through the the customer shares. considerate.” F6 adaption of a lifestyle and behaviors.
Appendices 157