AIDS, Sexual Behavior, and Intravenous Drug Use (1989)

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2 Sexual Behavior and AIDS It is now widely recognized that controlling the spread of the AIDS epidemic will require a national effort to persuade a sizable fraction of the population to modify their sexual behavior. The effort will be most crucial for those individuals who are now sexually active with multiple partners (concurrently or serially) and for young per- sons who will become sexually active in future years. This urgent need, in turn, has generated a renewed awareness of the lack of an adequate scientific understanding of human sexual behavior (includ- ing its emergence and development) and the necessity for rigorous programs of basic research in this field. In this chapter, we describe what is currently known about (past and present) human sexual be- havior and the types of data collection efforts needed to provide basic information from which to fashion the kind of understanding that is now required. STATUS OF THE RESEARCH FIELD In the United States, research on human sexual behavior has always been a high-risk undertaking in which there has been little public investment. Earlier in this century, the paucity of scientific research on human sexual behavior led to an effort at the National Research Council (NRC) to organize and promote such research. In 1922, with the support of the Rockefeller Foundation, the NRC established the Committee for Research in Problems of Sex, which played a major role in identifying and supporting fundamental research on sexual behavior. Until it was disbanded in 1963, the committee provided research grants and in some cases made arrangements for 73

- ~ 74 ~ UNDERSTANDING SPREAD OF HIV direct funding by the Rockefeller Foundation for efforts ranging from studies of hormones and the biology of sex to the pioneering social research of Albert Kinsey and his collaborators (AberIe and Corner, 1953). Despite the committee's efforts, however, the AIDS epidemic has highlighted the gaps in scientific knowledge about the sexual behavior of contemporary Americans. These gaps compromise prac- tical attempts to cope with the AIDS epidemic and handicap efforts by health scientists to predict its future course. For example, as noted in Chapter 1, estimates of the number of persons infected with HIV (Public Health Service, 1986; CDC, 1987) have used Kinsey and colleagues' (1948) data to estimate the number of men in the United States who have sex with men. As Chapter 1 also noted, however, Kinsey's data have been widely regarded as unreliable for use in making such estimates because they were not collected by probability sampling and because they pertain to the population of 1938-1948. Similarly, promising mathematical models of the dynamics of the spread of HIV infection require ciata on a wide range of sexual behaviors; these data currently are not available. For example, the distribution of the number of sexual contacts (both current and new partners) among indivicluals in a population has been shown to be important to the spread of the virus (May and Anderson, 1987~. The number of contacts is a key determinant of the "reproductive rate" (Ro) of the epidemic, which is defined as the average number of new cases of infection generated by a single infected individual. There are currently no reliable ciata on sexual contacts for the national population; there are also no such data for groups with elevated risks of transmitting or contracting HIV infection (e.g., men who have sex with men, TV drug users, heterosexuals with many sex- ual partners). Indeed, there is no reliable information on the size of the nonmonogamous heterosexual population. The lack of such data makes predictions about the future spread of AIDS extremely uncertain. These examples illustrate but two of a large number of crucial needs for reliable ciata on human sexual behavior. AIDS and HIV- related concerns present the most pressing needs for better data; yet over the longer term, we anticipate that the outcomes of such research will find application in many areas besides AIDS for instance, in population studies and in the treatment of sexual dysfunction. In this chapter, we review the types of data on human sexual behavior that will be needler! to understand and predict the course of

SEXUAL BEHAVIORS ~ 75 the epidemic and to design effective interventions to bring about the behavioral changes requirec! to control the epidemic. We also describe the available data on sexual behavior in the United States, including trends in adolescent and adult sexual behavior, same-gencler sex, and prostitution; the methodological and other problems that need to be overcome to obtain more reliable and valid cIata about relevant aspects of sexual behavior in the United States; and the role of anthropological techniques in this effort. Finally, we present a series of recommendations intended to improve understanding of the sexual behaviors that spread HIV infection. NEEDED DATA Two classes of data are urgently needed in the confrontation with AIDS/HIV. One class of data is required to understand the dynamics of HTV transmission that sustain the epidemic so as to predict the epidemic's future course. This class includes a mix of biological and social data. Although there may be differences of opinion on cletail, there is widespread agreement on the common core of basic information needled for these purposes. Another class of ciata is needed to control the epidemic's spread by reducing the frequency of behaviors that are likely to transmit the virus. This class is not as well defined as the first class of data because the task calls for a fundamental understanding of the factors that explain the clevelopment and expression of human sexuality (including its variety, social malleability, and other aspects). Data Needec! to Understand the Epidemic's Future Course Understanding the future course of the HIV/AIDS epidemic requires both at present and at regular intervals in future years a vari- ety of data on sexual behavior. Purely statistical extrapolations of current trends, such as those used by CDC (Public Health Service, 1986), can provide useful short-term predictions of the number of AIDS cases in the future, and they do not require a model of the underlying dynamics of disease transmission. For Tong-term predic- tions, however, it is necessary to understancl the underlying dynamics of transmission within particular risk groups (see, e.g., May and An- clerson, 1987~. Such understanding in turn requires more extensive knowlecige of three key elements of HIV transmission.

76 ~ UNDERSTANDING SPREAD OF HIV First, it is necessary to know the probability that an infected inctiviclual will transmit the infection to a partner (including male- to-male, maTe-to-femaTe, female-to-maTe, or female-to-femaTe trans- mission through sexual acts or by needle-sharing). The transmission probabilities in these instances depend on the kind of contact in question and the duration of the partnership, as well as on a variety of other factors. Transmission probabilities are not well understood at present; they are probably most uncertain for heterosexual trans- · . . mlsslon. Second, data are needed on the rates of acquiring new sexual partners (or neecIle-sharing partners) among specific groups. Such ciata include not only the average number of new sexual partners acquirer! each year but the variation in this number as well. Persons who acquire new partners at a high rate play a (disproportionate role in the transmission of infection, as they are both more likely to acquire and more likely to transmit infection. Thus, in both an epiclemiological and a mathematical sense, sexual contacts (or neecIle- sharing contacts) in a group cannot accurately be characterized by "average" individuals or "average" behavior. Data are also needed on the relative frequency of behaviors that have markedly different likelihoods of transmitting infection (e.g., anal, vaginal, or oral sex). Similarly, information is needed about the extent to which awareness of HIV/AIDS transmission has altered behavior (particularly with respect to the use of condoms and spermicides) in ways that may reduce transmission. Third, it is essential to know some key facts about the natural history of HIV infection, an area of knowledge in which, currently, uncertainties abound. There is considerable variation in the time that elapses between a person's acquiring HIV infection and the appearance of full-blown AIDS. The current best estimate is that the mean incubation period is ~ years, but as data spanning more time become available, it seems likely that this estimate will increase.) There is also uncertainty about the time-course of infectiousness. Evidence is now accumulating that suggests that infectiousness varies over the course of the disease. It appears that it may be elevated in the early phase of HIV infection and again at the onset of AIDS itself (as the immune system colIapses) but that it may remain relatively 1The current estimate is that the majority of HIV-seropositive individuals will go on to develop AIDS, and it is not impossible that 100 percent of seropositive individuals may eventually develop full-blown AIDS (IOM/NAS, 1988:35-36~. See also the projections of Lui and colleagues ( 1988~.

SEXUAL BEHAVIORS ~ 77 Tow at other times (e.g., TOM/NAS, 1988:38; Anderson and May, l988:Figure 1~. The basic reproductive rate (Ro) of an infection within a partic- ular population determines whether the infection has the potential to generate an epidemic in that population. The reproductive rate is essentially the number of new cases of infection produced, on aver- age, by each infected individual in the early stages of the epidemic, when essentially all contacts are themselves not infected. So, for example, if Ro is less than 1.0 for heterosexual transmission of HIV in the United States, on average, each case of HIV infection will produce fewer than one subsequent case, and the process will not be self-sustaining. There will be some chains of HIV transmission in which men will infect women who will then infect men and so on, but they will be few and short. If Ro is larger than 1.0, however, such chains will be more numerous and longer, and a "chain reaction," or epidemic, will be generated. The larger the value of Ro, the shorter the time it takes for the number of cases of infection to double. It is clear that Ro exceeded 1.0 among gay men in large U.S. cities in the late 1970s and early 1980s and that it exceeds 1.0 today among {V drug users who share needles. It is also clear that Ro exceeds 1.0 among the heterosexual populations of many parts of Africa. At present, it is unknown whether Ro is large enough (greater than 1.0) to engender a self-sustaining epidemic with purely heterosexual chains of transmission in the United States. The basic reproductive rate for a defined risk group depends on the three factors discussed earlier: the transmission probability, contact rates, and duration of infectiousness in that group. In the early stages of an epidemic, Ro can be estimates! by multiplying the values of these three factors: the probability that infection will be transmitted to any one new contact (sexual or needIe-sharing partner), the average number of new contacts each year, and the number of years over which the infected incliviclual remains infectious. It should be noted that the reproductive rate for HTV infection combines the fundamental biology of the virus (which determines the incubation interval, for example) with behavioral factors (e.g., rates of acquiring new sexual partners, whether condoms are used, and so forth). Thus, Ro can differ from one risk group to another and can change over time in response to behavioral changes. If Ro for heterosexually transmitted HTV in the United States is less than 1.0, no "second-wave" epidemic, spread purely by hetero- sexual contact, is possible. Moreover, even if Ro does exceed 1.0 in the heterosexual population, the doubling time for the second-wave

78 ~ UNDERSTANDING SPREAD OF HIV epidemic may bear little relation to that of the "first wave," which spread mainly among gay men and {V drug users. Furthermore, if the cloubling time of this second, heterosexual wave is much longer than that of the first wave for example, 5-10 years or more the resulting patterns of spread among heterosexuals may go unnoticed against the much larger background of cases among homosexuals and {V drug users. Data Needler! to Unclerstanc! the Epiclemic's Dynamics Estimating future demands on hospitals and other public health ser- vices requires reliable models of HIV transmission dynamics. Such epiclemiological models, in conjunction with knowledge of the under- Tying biological and behavioral variables, can also help in assessing the relative effectiveness of different kinds of behavioral change and guiding the development of effective public health education.2 Data neecis are driven by immediately relevant questions of dis- ease transmission, progress, and control. The resulting intellectual strategy is to design new research looking for the "facts about sex" in order to answer those questions. Such facts, particularly when reliably collected and combined with a sensitive understanding of the cultural boundaries between social groups, may be of consider- able use in the medical and social management of the HIV/ATDS epidemic. Yet the committee would point out that there are risks in a strategy of proceeding from an interest in disease to research on the "facts" of sexual conduct. These risks involve the possibility that concerns about disease will reinforce the tradition of treating some aspects of sexual conduct as social or medical "problems." To understand the motives, clevelopment, and varieties of human sexual behavior, it is crucial to understand the systems of meaning and action—the cultural context in which the "facts of sex" are embedded. The facts remain the same, but understanding may differ. Different understandings in turn may have important consequences for designing effective educational efforts to encourage self-protective behaviors. 2Efforts to reduce risky behavior in individuals often do not require detailed knowledge of the transmission dynamics of the epidemic. Nevertheless, efforts directed toward accessible individuals can go hand in hand with broader, population-level studies of the relative effectiveness of different broad categories of public education. Individual counseling and activities to reduce risky behavior in particular groups that are accessible to AIDS prevention efforts are not alternatives to mathematical modeling, given that such modeling may lead to the development of intervention strategies that make maximal use of scarce resources.

SEXUAL BEHAVIORS ~ 79 In the following sections of this chapter, we review available data (largely collected prior to the onset of the AIDS epidemic) on sexual behavior in the United States. The history of research on human sexuality, at least in the United States, can be divided somewhat crudely into the pre-Kinsey and post-Kinsey eras. Despite the fact that Kinsey himself cited a number of questionnaire and interview surveys of sexual behavior conducted in a variety of countries as early as the first decade of the twentieth century (Kinsey et al., 194S, 1953), it was the publication of the two "Kinsey reports" Sexual Behavior in the Human Male (1948) and Sexual Behavior in the Human Female (1953) that dramatically shifter! the study of human sexuality away from its predominantly clinical and psychopathological concerns. In doing so, Kinsey and his coworkers respondent to the call of Havelock Ellis in the 1920s, who proposed that sex researchers expand their interests beyond the asylum, the prison, and the clinic to study "fairly normal people" (Gagnon, 1975~. In the attempt to accomplish this task, no matter how provisionally, the Kinsey studies helped to change the way in which sexuality was approached in American society: first, by establishing sexuality as a legitimate object of scientific inquiry; second, by offering a blurred but still discernible "snapshot" of what some people were (loin" sexually; and thircl, by offering a different definition of what was thought to be norma1t sexuality. THE KINSEY STUDIES It is not easy for those who have grown up in the 1960s and later to understand the extraordinary impact of the Kinsey studies in a society in which ignorance about sexuality was pervasive. Even those who were already adults when Kinsey's work first came to the na- tion's attention probably find that their memories of that world have been corroclec3 by time and the deluge of sexual materials andref- erences that have characterized the past three decades. The Kinsey studies engendered extensive, if not always thoughtful, discussions of sexuality in a society in which public talk about sex had been restricted to the vulgar, the moralistic, or the psychoanalytic. After their publication, words such as masturbation, homosexuality, or- gasm, vagina, extramarital sex, clitoris, and penis could be spoken of in more or less polite company (although not in the New York Times of the period). People knew (or thought they knew) that one man in three had had sex at least once with another man; one married woman in four had sex outside of marriage; and the average rate of

80 ~ UNDERSTANDING SPREAD OF HIV intercourse in marriage was between three and four times a week for couples in their 20s. The "facts" were out of the closet and seemed unlikely to be put back in. The vast outpouring of public discussion was based on what were two Tong and seemingly indigestible books, the first reporting approximately 3,000-5,0003 face-to-face interviews with men, the second reporting 5,940 similar interviews with women. Quality of the Kinsey Data Because the Kinsey studied are cited even today as a primary source of information on sexual behavior, it is valuable to review their design. To assess the quality of these data and their appropriateness for estimations of contemporary sexual behavior, it is important to examine two methodological aspects of the Kinsey studies: (1) the interview scheclule, including its topical coverage, the interviewing procedures, and the interviewers; and (2) sampling—the method of gathering cases. These two aspects are discussed below; a third major aspect, the impact of the Kinsey studies on conceptions of sexual normality, is discussed later in the chapter. The Interviews The greatest strengths of the Kinsey studies were probably their coverage of a wide variety of sexual topics and the quality of the interviewing. The theories that informed the interview were quite general; they primarily reflected Kinsey's prior training as a tax- onomist who had made his reputation in the ecological and evolu- tionary stucly of the gall wasp. Kinsey was fun(lamentally interested in the behavioral events (as opposed to the attitudes, motives, or emotions) that composed an individuaT's sexual history, and he saw those events as expressions of the interaction between the universals 3This range reflects the fact that different analyses reported in the first volume were done at different times and that during the intervals, additional cases accumulated. (A Oh h ~ or] ~ n r1 T^h ~ curare ~ 1 (] 7(] . Cl ~ ret ~+ Hi. ~~ ~_V^~ .L VVAAAA~VAI. ~~-I-.-J revue. ... in those days we lacked computers and our card sorters were slow. A relatively simple table could easily take a full day or two of sorting assuming the machine was available. Consequently, some tabulations were made a year or more before others and since our interviewing continued, our Ns varied. Thus, Table 62 in the Male volume tSexual Behavior in the Human Male] shows 3,012 white males in our earliest age category (which should include all post-pubescents), yet in Table 63, the number is 3,925. Still later in Table 92 the N has risen to 4,625. This particular table was made in May 1947 one of the latest prepared." 4Additionally, the volumes Pregnancy, Birth and Abortion (Gebhard et al., 1958), Sex Offenders: An Analysis of Types (Gebhard et al., 1965), and The Kinsey Data: Marginal Tabulations of 1938-1963 Interviews Conducted by the Institute for Sex Re- search (Gebhard and Johnson, 1979) contain important information about these studies.

SEXUAL BEHAVIORS ~ 81 of the mammalian heritage and the specifics of social learning in a cultural context. The interview thus embodied a general scientific perspective rather than a specific set of hypotheses to be tested. The interview schedule consisted of a dozen topical areas that could be covered in approximately 300 questions (Gebhard and John- son, 1979:13-14~. Interviewers were not restricted to the specific framework of the schedule, however, as the goal was to obtain infor- mation in an area rather than to ask precisely worded questions. The interviewers memorized the schedule, changed wording to conform with usage by the interviewee, and recorded only coded responses (to maintain confidentiality). The schedule was designed by Kinsey in the late 1930s and was consoliciated by the early 1940s. Its continuing use had the benefit of maintaining comparability in data that were collected over nearly 25 years, although at some cost to the ability to learn from mistakes or adapt to new knowlecige. Kinsey wanted the social interaction involved in the interview process to be businesslike and nonjudgmental. Nothing was to be disapproved of or found shocking by the interviewers. Interviews were most often conducted outside the home, in institutional or com- mercial settings in which appointments could be ma(le and anonymity preserved. Almost every possible sexual topic was included: people were routinely asked about masturbation, nocturnal orgasm, intercourse (in all its variations), homosexual contacts, animal contacts, and sex- ual fantasies. Respondents were asked in considerable detail about the ages at which they engaged in these behaviors, frequencies, tech- niques, partners (when appropriate), and rates of orgasm. Those inclivicluals with extensive histories of homosexuality, prostitution, sex offenses, sadomasochism, and the like were queried still further. Few studies conducted since that time have been as sharply focused on sexual behavior or so exclusively interested in sexual conduct for its own sake. More recent studies of sexual behavior have often asked only a few questions about sexuality, usually in the context of another inquiry that was defined by some social problem (e.g., adolescent pregnancy). There are significant differences between the Kinsey interview and the interviews that characterize most modern surveys. Current surveys that use face-to-face (lata gathering usually have fixed inter- view scheclules; interviewers are required to conform to the precise wording and order of questions printed on the survey questionnaire. In adclition, a changing technology of data gathering has produced other variations:

82 ~ UNDERSTANDING SPREAD OF HIV · survey interviewers are most often women, many inter- viewers are involved in each survey, and interviews are often done in the subject's home; · most surveys even studies that have some relation to sexuality (e.g. studies of reproduction and fertility) do not focus entirely on sexual matters but instead ask such questions infrequently and usually as modest additions; and . in many cases, interviews are conducted by telephone. Sampling It has long been recognized that one of the greatest faults of the Kinsey research was the way in which the cases were selected: the sample is not representative of the entire U.S. population or of any definable group in the population. This fault limits the comparability and appropriateness of the Kinsey data as a basis for calculating the prevalence of any form of sexual conduct. The population segment best represented by the Kinsey inter- views can be described as a "chunk" of the white, youthful, college- educatecl U.S. population whose adolescence and young adulthood were lived during the late 1920s, the Great Depression, and World War Il. Of those interviewed, 96 percent were white, and their median age was 24;5 moreover, 68 percent of those interviewed were 30 years of age and younger and were thus able to offer evidence on only the first quarter of adult sexual life. Some respondents were specifically chosen because they were delinquents, criminals, or sex offenders; 5This and subsequent characterizations of the Kinsey cases are taken from Gebhard and Johnson (1979:47-51, Tables 1-3~. This particular description refers to Kinsey cases interviewed at any time from 1938 to 1963. (Table 2-1 shows the number of cases collected during different periods.) Gebhard and Johnson's (1979) tabulations are restricted to what they call Kinsev's "basic sample," which they define as including "postpubertal individuals who were never convicted of any offense other than traffic violations and who did not come from any sources which we knew to be biased in terms of sexual behavior" (p. 41~. This basic sample included 177 black men, 223 black women, 4,694 white men, and 4,358 white women, all of whom had attended college for at least one year. The basic sample also included 766 white men and 1,028 white women who had not attended college. Kinsey's basic sample does not include cases identified by Gebhard and Johnson as (1) homosexual (defined as "postpubertal individuals who had at least 50 homosexual contacts or who had at least 20 sexual partners of the same gender as the individual" [p. 43~; (2) delinquents (defined as "postpubertal individuals who have been convicted of a felony or misdemeanor other than a traffic violation" tp. 453~; and (3) "special groups," which are described as "simply residual categories of individuals who cannot be assigned elsewhere because of some sample bias or because of some other special characteristic" (p. 45~. This last "residual" group included 380 prepubertal and 999 postpubertal males, and 156 prepubertal and 717 postpubertal females. ,. ..

SEXUAL BEHAVIORS ~ 83 TABLE 2-1 Year of Interview by Gender for Persons Interviewed Using the Original Kinsey Interview Schedule Males Year Females Number Percentage Number Percentage Prewar, 1938-1941 1,910 19.5 436 5.6 Wartime, 1942-1945 3,353 34.3 3,740 48.4 Postwar, 1946-1952 2,907 29.7 3,413 44.2 Early 1950s 1953-1956 1,461 14.9 58 0.8 Post-Kinsey, 1957-1963 146 1.5 78 1.0 Total 9,777 7,725 SOURCE: Gebhard and Johnson (1979). most of the remainder were, in the tradition of most sex research, college eclucated. About 84 percent of the men and women inter- viewed hac! some college education, and 45 percent were in college at the time of the interview. Perhaps most striking is that 25 percent of the college-educated women had been to graduate or professional school, as hacT 47 percent of the college-educated men. About one half of the female sample was interviewed during World War II, and many others were interviewed shortly afterward (see Table 2-1~. Perhaps more important than the composition of the sample were the methods by which the cases were collected. Both the difficulties of sampling on a sensitive topic ant! Kinsey's confidence that the sheer force of accumulated cases6 would eventually translate into representativeness severely compromised the usefulness of the data for making estimates of prevalence that coup be generalizecI to any larger group or to the overall population. Kinsey gathered cases in a variety of ways. Many respondents were interviewed as the result of gaining access to a group through a contact person: for example, a faculty member sympathetic to Kinsey's goals might allow him to speak to a class to recruit students, or a prison administrator would offer access to an inmate population. 6Kinsey hoped to gather lOO,OOO interviews to complete his research (see the dedication to the 1948 volume); some 17,000 had been completed by the time of his death.

84 ~ UNDERSTANDING SPREAD OF HIV In other cases, lectures to less organized groups such as PTAs were used as occasions to ask for volunteers. These two types of groups became what Kinsey later described as "100 percent groups" that is, groups in which he estimated that he interviewed all (or almost all) of those exposed to his request for cooperation. In these "sample" groups, Kinsey believed that he was solving some of the problems of sampling, particularly those of volunteer bias. Yet neither the contact persons nor the groups to which they offered access were sampled from some larger list; consequently, the final sample could never, in principle, have been a probability sample. In addition, many of the cases were friends of friends who were recruited through networks of referrals. It is difficult even to begin to consider how these cases could be acIded together or "corrected" to make what at best could only be marginally satisfactory population estimates. This point is made most trenchantly in the major statistical review of the Kinsey re- search (Cochran et al., 1953~. Utility of the Kinsey Data Despite their limitations, the Kinsey ciata published in 1948 and 1953 (based largely on those individuals in the sample who grew up in the 1920s and 1930s)7 remain the most widely known and referenced data on American sexual behavior. Portions of the studies have been used as historical benchmarks for the estimation of sexual change over the last half century (e.g., the rates of premarital and marital sexual conduct). Other results, particularly those relating to the prevalence of extramarital intercourse, masturbation, intercourse with female prostitutes, and homosexual conduct by men anti women, are sometimes cited as if they applied to the contemporary U.S. population. Given the inadequate samples on which the estimates are based;, the committee believes these uses are inappropriate even for the periods in which the data were gathered. It is also likely that the quality of the data varies across various sexual topics and measures. One might expect common forms of conduct (e.g., masturbation and heterosexuality before and within marriage) to be reasonably well reported. However, information on conduct that is relatively rare (e.g., homosexuality, intercourse 7The apparent discrepancy in the times of "growing up" cited here (192~1930) and those cited earlier (1920-World War II) reflects the different periods during which data were gathered. The earlier characterization referred to the entire body of Kinsey data, which was gathered between 1938 and 1963.

SEXUAL BEHAVIORS ~ 85 outside of marriage, contact with prostitutes, and bisexuality) is quite sensitive and more likely to be misreported. Yet these are the very forms of sexual conduct that are pertinent to an understanding of the spread of HIV/AIDS. There is a tendency to use Kinsey (and other) inadequate numbers in the absence of good data, but in so doing, there is a serious risk of making wrong predictions and creating the illusion that more is known about sexual behavior than is in fact the case. Another problem with the Kinsey data is a result of focus rather than method. Kinsey was most interested in the frequency of various sexual activities, expressed primarily in terms of orgasm. His work was based on a concept of differential "energy" (including sexual energy) of the indiviclual organism, which led to a concern with these measures. A more social model of sexuality wouicI focus on sexual partners and networks of sexual partnering, as it is likely that types and numbers of partners actually shape frequencies of conduct and the specific sexual practices performed. A partner- ctriven model of sexuality might also satisfy more adequately the needs of epidemiology in relation to the transmission of HIV. Kinsey and the Issue of Sexual Normality The public uproar that greeted the publication of the Kinsey reports was a signal that something more than a scientific event had oc- curred. Kinsey was violently assailecl by representatives of religious groups, conservative congressmen, and some social research method- ologists. He and his work were caricatured in the press. Some people have claimed that the ferocity of this attack may well have short- ened Kinsey's life (W. B. Pomeroy, 1972:381~. Given Kinsey's dual claims that sexuality could and should be the object of detached scientific inquiry and that sexual normality rested ultimately on the mandates of the mammalian origins of the human species this at- tack might have been expected. IndeecI, there is evidence that some conflict was foreseen. In setting forth arguments for the legitimacy of sex research, Alan Gregg of the Rockefeller Foundation argued in the preface to Sexual Behavior an the Human Male (Kinsey et al., 1948) that Certainly no aspect of human biology in our current civilization stands in more need of scientific knowledge and courageous hu- mility than that of sex. As long as sex is dealt with in the current confusion of ignorance and sophistication, denial and indulgence, suppression and stimulation, punishment and exploitation, se- crecy and display, it will be associated with a duplicity and

86 ~ UNDERSTANDING SPREAD OF HIV indecency that lead neither to intellectual honesty nor human dignity. This was no neutral claim but an assertion of the legitimacy of objective, cletached, dispassionate inquiry as against the indecent and dishonest social arrangements that were then current. Moreover, these were and are "fighting words" because they stake out a large area of human conduct for scientific inquiry and judgment. The very claim for the legitimacy of science in the area of sexuality was an attempt to change the "rules of the game" that defined what conduct was normal and what was abnormal. Kinsey went even further, however. He attempted to counter the traditional religious view that sexual virtue was entirely composed of heterosexual activity in the pursuit of reproduction inside the bonds of marriage, as well as the orthodox psychoanalytic revision of this traditional view, which admitted the existence of other forms of sexual expression but treated them as either perversions from or preludes to the sexual "normality" found in mature heterosexual committed relationships. Kinsey's counter to these views was to take a strong biological line that emphasized the evolutionary history of the species rather than the defective status of the indivictual. He arguer! that homosexuality, masturbation, and oral sex (to take the triad he most often discussed when dealing with these issues) were common activities in "the mammalian heritage" as well as among human groups in which sexual behavior was not culturally repressed. Hence, such activities represented the diversity of nature rather than perversions and deviations from biological or cultural standards for the sexually correct individual (Kinsey et al., 1948~. This extraordinarily original argument allowed Kinsey to bring what was thought to be unnatural behaviors uncler the umbrella of a broacT, evolutionary perspective. Sexuality could thus be treated as part of a natural world that should not be limited by the artifices of culture. The Kinsey research reflected! an important moment in the his- tory of science and society in the United States. It opened the door to further work and changed the way in which sexuality was talked about in this country. Yet for reasons of method and history, it can- not provide answers to the questions that have been raised by the AIDS crisis: it cannot replace carefully conducted, contemporary research.

SEXUAL BEHAVIORS ~ 87 After the Kinsey Studies The various social and cultural forces of the 1930s ant! 1940s that prompted the original Kinsey studies, and the example of those studies, did not produce a continuing tradition of sex research. Par- ticularly lacking are contemporary studies of . sexuality outside marriage, . sexuality with persons of the same gender (homosexual- ity), · sexuality with persons of both genders (bisexuality), . sexual contacts for pay (female and male prostitution), and . variations in sexual techniques across various types of sexual pert nerings. There is somewhat better information on heterosexuality among adolescents and young people (although these (lata are usually re- stricted to young women and to such topics as ages of initiation and rates of intercourse rather than partners and techniques) and coital rates in marriage. Both of these topics have been included in national surveys as well as in studies of more limited populations that cover a more extensive range of questions. In abolition, since the publication of works by Masters and Johnson (1966), sexual dysfunction among married couples has received a great clear of attention, largely in clinical or experimental studies.8 The lack of a robust scientific tradition of research on sexuality has not, however, reduced the demand for and the supply of "facts" about sexuality. Research quackery abounds. "Surveys" have been conducted by journalists, women's and men's magazines, and en- terprising professionals using invalid and unreliable questionnaires ant! collections of respondents whose population characteristics and response rates are unspecified. (Smith tin this volume] provides a review of one well-publicized report on sex in contemporary America tHite, 1987~.) Incliviclually, such "reports" are transient sources of 80ther research programs in sexuality of less immediate relevance to the committee's concerns have included studies of sexual offenders, sexual contacts between adults and children, sexually explicit materials (studies of both their availability and their effects), and sexual violence against women. Such studies are important in a number of ways, and they may merit careful review in future work. Studies of sexually explicit materials, for example, are important for measuring change in the sociosexual climate in the society. Studies of sexual abuse and violence will be critical elements in understanding some of the sources of sexual difficulties experienced by both children and adults. In addition, there has been a steady growth of research on sexual psychophysiology, particularly as it relates to sexual dysfunction.

88 ~ UNDERSTANDING SPREAD OF HIV fun, fantasy, and profit a short flash in the media pan. Collectively, they may have a more negative character. They become part of the penumbra of nonfacts and fake knowledge that informs the media and the public. Indeed, in the absence of scientific data, numbers from some of these 'surveys have 'been cited in research, textbooks, or serious science journalism. To the degree that science has abandoned the task of sexual enlightenment,' others have filled the gap. TRENDS IN HETEROSEXUAL BEHAVIOR IN ADOLESCENCE AND YOUNG ADULTHOOD The extensive transformation of the role of sexuality in the lives of young people since the turn of the century has generated widespread social concern, especially since World War Il. Kinsey found changes among young people cluring 1920-1945. His studies were followed by a surge of sociological interest in the premarital sexual concluct of young people as an element in changing courtship patterns (see reviews by Cannon and Long t1971] covering the 1960s and Clayton and Bokemeier [1980] covering the 1970s). Since the 1970s, research has been undertaken by both sociologists and demographers, moti- vatecl primarily by a concern for the rising rate of births among young unmarried women (e.g., ZeInik and Kantner, 1980; Ho~erth et al., 1987~. Although the data used in the various studies are not always strictly comparable, taken as a whole, they document impressively the increase in premarital sexual activity in the Uniter! States. Kinsey's Finclings Figure 2-1 shows the cumulative percentage of women reporting premarital sexual intercourse by their clecade of birth. Among ever- married women9 who were still not married by age 20, only ~ percent of those born before 1900 reported premarital intercourse; however, for women born during the first three decades of the twentieth cen- tury, IS, 23, and 21 percent reporter! premarital intercourse. Com- menting on these results, Kinsey and his collaborators (1953:298) observed: "This increase in the incidence of pre-marital coitus, and the similar increase in the incidence of pre-marital petting, constitute the greatest changes which we have found between the patterns of sexual behavior in the older and younger generations of American 9Ever-married women include those currently married and those who have been married at some point in their lives E.g., widows, divorcees.

SEXUAL BEHAVIORS ~ 89 100 LU ~ 80 An O 60 LIJ 40 By LL () 20 llJ Q o Women Decade of Birth 1 900-1 909 .~ 1 920-1 92' I ., _~— , , , , 1 5 10 15^ 20 25 Bf. 1900 30 35 40 45 AGE FIGURE 2-l Cumulative percentage of women reporting premarital sexual intercourse by their decade of birth. Samples were restricted to ever-married women who had not married by the age shown in the figure. SOURCE: Kinsey and colleagues (1953:Figure 50 and Table 83~. females." In contrast, they found much smaller changes in the re- portec! prevalence of premarital intercourse among young men in this same period. Figures 2-2a and 2-2b show the cumulative percentages of men, by education, reporting premarital sexual intercourse.~° Kinsey reports more substantial changes in male frequency of sex with "companions" than in frequency of sex with prostitutes. The difference consisted mainly of a change in the frequency with which men reported having sex with prostitutes not a change in the percentage of men who hacl at least one such experience. Com- plementing the fincling that women born after 1900 were more likely than those born before 1900 to report premarital sex, men in the younger cohort reported greater frequencies of sex with companions and reduced frequencies of sex with prostitutes. These differences iOThe figures for men and women are not strictly comparable because the men were split into two groups by age at the time of the interview and the women were grouped by year of birth. The older generation of men are those "who were 33 years of age or older at the time they contributed their histories" (Kinsey et al., 1948:395~. The point of division of the men by birth year can very roughly be estimated as a birth year in the range 1906-1912. Because the interviewing stretched over several years, the two groups overlapped in birth dates. Gebhard and Johnson's (1979:32-35) history of the interviewing suggests that most of the interviews reported in Kinsey's 1948 volume were conducted from 1939 to 1945 or 1946. In the sample interviewed in 1939, those older than 33 were born in 1906 or before; men interviewed in 1945 were over 33 if they had been born in 1912 or earlier.

90 ~ UNDERSTANDING SPREAD OF HIV 0 100 ~ 80 o LL (D 60 z in O 40 LO CD ~ 20 By LL] V ILL O 100 ~ 80 o ~ 60 CD z oh LL 40 o lo 20 t.Ll o rA. Men--0-8 years' education ~ | Older Younger / alp 10 15 20 _ ~ ~ rat 25 AGE B. Men~college-educated 30 35 40 fin Younger, I, Older _~99'~ 5 10 15 20 25 30 35 40 AGE FIGURES 2-2a and 2-2b Cumulative percentages of men reporting premarital sexual intercourse by educational level. NOTE: In their text, Kinsey and colleagues imply that Figures 2-2a and 2-2b are based on a sample of men who were single at the time of the interview. This sample would be somewhat different from that used to construct the graph for women shown in Figure 2-1. SOURCE: Kinsey and colleagues (1948:Figures 111 and 116~. led Kinsey to the curious speculation that the "sexual outlet" for- merly spent on prostitutes was now to be spent on companions: "The drives against prostitution have succeeded in diverting a third to a half of the intercourse that mates used to have with prostitutes to

SEXUAL BEHAVIORS ~ 91 pre-marital activities with other girls" (Kinsey et al., 1948:413~. This image of mate sexual energy waiting to be expenclec! in one place or another is an important example of the asocial character of Kinsey's basic sexual theory. Studies After Kinsey The Kinsey studies were followed and extended by a number of social and behavioral researchers who investigated patterns of association, emotional intimacy, attitudes toward premarital sex, and premari- tal intercourse (e.g., I. Reiss, 1960, 1967; see also the reviews by Cannon and Long t1971i, and Chilman 1978. These researchers generally studied college students, although some managed to work with high school students or recruited "matched" samples of non- college students from the same geographical area (e.g., DeI,amater and MacCorquodaTe, 1979~. The early studies in the 1950s tended to focus on attitudes toward premarital sex; those in the 1960s shifted more specifically to the question of premarital sexual behaviors. This research was primarily driven by concerns about the changing role of sexuality in the (heterosexual) courtship patterns of young people. In contrast to Kinsey's wide-ranging inquiries, post-Kinsey investi- gators dealt rather clelicately with heterosexual issues and not at all with other aspects of the sexual lives of young people. The 1970 Kinsey Institute study also produced complementary findings for numbers of reported heterosexual partners. Table 2-2 shows the number of premarital heterosexual partners reported by gentler and decade of birth for ever-married adults in the sample. This table clearly documents the trend over the century of a greater number of sexual relationships for adults prior to marriage. More- over, the table shows that this trend, although evident to some extent for men, is much more dramatic for women. Unfortunately, if one wishes to draw inferences about the fre- quency of particular sexual behaviors in the American population, both Kinsey's data and most later research are restricted either by lack of a sampling design or by sampling from a limited population (e.g., students at the University of Wisconsin in 1973~. A num- ber of these studies, however, provide suggestive results and test methodologies that are instructive for further research; estimates of the prevalence of premarital intercourse from selected studies are presented in Appendix B. Although there is considerable variability iiAdapted from Klassen and colleagues, Table ~ (in this volume).

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94 ~ UNDERSTANDING SPREAD OF HIV among the studies, the data suggest a slow evolution through the late 1960s with increasing proportions of young women engaging in intercourse befor@ marriage, followed by more rapid increases in the early 1970s. The first national probability sample survey that asked nearly as wide a set of questions on sexual conduct as the Kinsey research was conducted in 1967. It was relatively small (1,177 respondents) and was restricted to college students (Gagnon and Simon, 1987~. In a two-stage sample design, 12 schools were first selected from a sample list of accredited four-year colleges and universities; lists of under- graduates in the school directories were then used to sample stu- clents. The response rate for the study (counting as nonrespondents those students who could not be located) was 75 percent (Gagnon and Simon, 1987:13~. The survey covered masturbation (Atwood! and Gagnon, 1987), premarital coital and noncoital sexual activity (Gagnon et al., 1970; Simon et al., 1972), first coital experience (Carnes, 1975), menarche (Gagnon, 1983), sex education (Spanier, 1976), homosexual behavior, sources of sexual arousal (Berger et al., 1973), childhood sexuality, and experiences of women with victimiza- tion. The information gathered on specific sexual behaviors included ages, frequencies of conduct, numbers of partners, and sexual prac- tices (Gagnon and Simon, 1987~. In addition, data were gathered on contraceptive knowledge ant! practices. Because one goal of the study was to set sexuality in the context of normal psychosexual development, data on a wide variety of social, psychological, and background variables were also gathered. In general, except for the questions about homosexuality (for which there appeared to be sum stantial underreporting; see Gebhard [1972:27~), the data from this study were similar to those reported in studies of less representative samples of college students. A comprehensive national survey of the entire adult population (but covering a more restricted range of sexual behaviors) was con- ducted in 1970 for the Kinsey Institute by the National Opinion Research Center (NORC) of the University of Chicago. Unfortu- nately, because of a dispute among the investigators, little has been published from this important survey. (Some of the history of the study can be found in Booth [19881 and Klassen [1988~.) At the request ot the committee, the original investigators, with the assis- tance of National Research Council staff, have summarized some of the relevant data on heterosexual behaviors (Klassen et al., in this volume). The 1970 Kinsey Institute survey, particularly when combined ~ 1 · . . . ~ · · ~

SEXUAL BEHAVIORS ~ 95 with more recent studies of adolescent experience, provides impor- tant insights into temporal trencis in heterosexual experience among adolescents and young adults. For example, it is possible to use the retrospective reports of age at first premarital experience from several surveys to reconsider Kinsey and colleagues' (194S, 1953) analyses of temporal trends in premarital sexual behaviors. Figure 2-3a plots the percentages of men and women in the 1970 Kinsey Institute survey who reported a premarital sexual contact in which one partner came to a sexual climax (from Klassen et al., Table 3, in this volume). There is an upward trench from the cohort born at the beginning of the century through the cohort born in 1944-1949 for both men and women. Among ever-married men, the percentage reporting premarital sexual activity to the point of orgasm before age 19 rose from 41 percent for those born prior to 1911 to 79 per- cent for those born in 1944-1949. Among ever-married women, the rise is more dramatic (although the percentages consistently remain below those for men): the percentage reporting premarital sexual contact to the point of orgasm (by one partner) before age 19 rose from 5.5 percent for those born prior to 1911 to 50 percent for those born in 1944-1949. Similar results are found for sexual activity at younger ages. The percentage of young men reporting such behavior before age 16 rises from 15 percent (pre-1911 birth cohort) to 37 percent (1944-1949 birth cohort), while the corresponding female percentages rise from 2 percent to 15 percent. It is possible to combine the data from the Kinsey Institute study reported by Klassen and colleagues (in this volume) with more recent data to extend such analyses through time. First, however, issues of data comparability must be considered. The 1970 Kinsey Institute study die! not include a direct question on age at first intercourse. Instead, respondents were asked at what age they first had a sexual contact in which one partner (or both partners) came to a sexual climax (see the note to Figure 2-3a). There is no way to estimate what proportion of these activities involved sexual activities other than intercourse. Keeping this difficulty in mind, results from the 1970 Kinsey Institute survey can be comparer! with those of the 1982 National Survey of Family Growth (NSFG), shown in Figure 2-3b (Ho~erth et al., 1987~. The NSFG interviewed a national probability sample of women and asked a direct question on intercourse. i2Appendix Table B-6 (in this volume) presents data from the two studies for the same birth cohort (1944-19493. The percentage of this cohort in the NSFG who reported premarital intercourse by age 20 (46 percent) was somewhat lower than the percentage in the Kinsey Institute study (Klassen et al., in this volume) who reported sexual activity to the point of orgasm (56 percent). The results suggest that, as expected, the Kinsey

96 ~ UNDERSTANDING SPREAD OF HIV loo 90 80 70 IJJ 60 Z 50 ~ 40 r' 30 20 A. Men and Women Male Before Age 19 - Male Before Age 16 T Female Before Ace 19 T Female Before Age 16 T ~ Pre- 1 911 - 1 921 - 1 931 - 1 938- 1 944- 191 1 1920 1930 1937 1943 1949 BIRTH YEAR FIGURE 2-3a Percentages of ever-married men and women in the 1970 Kinsey Institute survey who reported a premarital heterosexual sexual contact in which one partner came to a sexual climax before ages 16 and 19. SOURCE: Klassen and colleagues (in this volume). Error bars denote approximately one standard error around estimates. NOTE: The 1970 Kinsey Institute study asked the following question to collect these data: "How old were you the first time you had sexual activity with someone of the opposite sex, when either you or your partner came to a sexual climax? If the first time was when you got married, please give your age at that time. This includes other sexual activity, as well as intercourse, if one of you had a sexual climax (orgasm)." Persons who reported that their first experience was in marriage are counted as having no premarital experience. One general observation from these figures is inescapable: there has been a massive change in the sexual behavior of American men and women during the twentieth century.~3 The ciata for women suggest both an increase in the proportion of those who are sexually- active and a decline ire the age at which the transition from being Institute data overestimate the incidence of sexual intercourse by a particular age. The trend across birth cohorts, however, appears to be roughly comparable in the two sources. It is not possible to rule out other sources of variation in these estimates, such as differences in the ages of respondents (and hence the length of recall involved) when they were supplying these data. Respondents in this cohort were 21-26 years old in the 1970 Kinsey Institute survey and 33-38 years old in the 1982 NSFG. Thus, respondents in the NSFG were recalling events 12 years more distant in time than those being reported in the Kinsey Institute survey. 13In addition to the well-known issues of reliability and validity of self-reported data on sexual behavior, it should be recognized that the sexual experiences of that fraction of a birth cohort that survives until the survey date may not be representative of the experiences of the entire cohort. For example, men in the pre-1911 cohort would have been 60 years of age or older at the time of the 1970 Kinsey Institute survey.

SEXUAL BEHAVIORS ~ 97 80 70 60 (D 50 ,L, 40 LL 30 20 10 B. Women T 3? ~ I 0 , , Female Before Age 19 Female Before Age 16 1938- 1941- 1944- 1947- 1950- 1940 1943 1946 1949 1952 BIRTH YEAR 1953- 1956- 1959- 1962- 1955 1958 1961 1964 FIGURE 2-3b Percentage of women in the 1982 National Survey of Family Growth who reported premarital heterosexual intercourse before ages 16 and 19. Error bars denote approximately one standard error around estimates. SOURCE: Hofferth and colleagues (1987~. coitally inexperienced to coitally experienced occurs. For adolescent females, marriage has ceased to be strongly tied to sexuality. Thus, fewer than 6 percent of American women born before 1911 reported any premarital sexual activity that led to orgasm by either partner prior to age 19. In contrast, more than 62 percent of women born in 1959-1961 reported premarital sexual intercourse prior to age 19. Changes in mate sexual behavior are harcler to track owing to the propensity of fertility studies the source of much rlata on sexual behavior to focus on women. The 1970 Kinsey Institute data (and the earlier observations of Kinsey and his colleagues), however, do suggest a shift in the character of premarital sex. Substantial propor- tions of young men at every observable point in the century report premarital sexual activity. Yet with the decline in their activity with prostitutes and an increase in the number of young women who were willing to have intercourse before marriage, it has been claimed that young men became increasingly involved in new forms of social ne- gotiation and responsibility in sexual relationships and that these changes led to a rearrangement of the timing, character, and social psychology of sexual life among young people. Thus, P. Y. Miller and Simon (1974) report a convergence between mate and female rates

98 ~ UNDERSTANDING SPREAD OF HIV of premarital intercourse in a household probability sample of young people in Illinois in 1973, and they argue that, even though there was not a full convergence, there was evidence that young men and young women are now governed by more similar standards of sexual interaction. Young men appear more likely than in earlier decades to talk about love and affection in the context of a sexual encounter, and young women appear more likely to seek intercourse without romantic attachment. Further Fences During the 1970s A series of three surveys of probability samples of American acloles- cents were conducted in 1971, 1976, and 1979 (Kantner and ZeInik, 1983a,b; ZeInik and Kantner, 1985), and they provide additional de- tail on the changes that occurred during the last decade. Because these surveys were motivated largely by concerns about adolescent pregnancy, they were understandably limited in the scope of informa- tion they collected on sexuality. Only a few questions about sexuality were included, and they were limited to heterosexual behavior.~4 Per- haps most revealing of the surveys' focus on fertility is the fact that the survey samples in 1971 and 1976 were exclusively female. Nonetheless, data from these surveys repeat and extend the basic findings of the previous analyses. Figure 2-4 shows, among women residing in metropolitan areas, a sizable increase in only eight years in the proportions of young people reporting the initiation of sexual intercourse: the percentage reporting intercourse before age 19 rose from 48 percent in 1971 to 71 percent in 1979; the percentage reporting intercourse prior to age 16 rose from 22 percent to 40 percent. These trends diiTer somewhat for black and white adolescent females. Along with younger age at onset of sexual activity, the percent- age of sexually active females (in metropolitan areas) aged 15 to 19 having more than one partner has increased somewhat. As Figure 2-5 shows, the percentage with multiple partners rose from just under 40 percent in 1971 to just over 50 percent in 1979 (Zeinik, 1983:Table 2-6~. Figure 2-6a displays the distribution of the number of sexual partners reported at 17 and 19 years of age by never-married women in the 1979 survey. Although roughly one half of the 17-year-olds lain the 1979 survey, data were collected on feelings about premarital sex; age, location, and planning for first intercourse; timing of second and last premarital intercourse; frequency of intercourse in the last 4 weeks and the last 12 months; total number of premarital partners and number of partners in the last 4 weeks; and the reason for discontinuing premarital sex.

SEXUAL BEHAVIORS ~ 99 80 llJ C:) X 40 Oh 111 CO Z 20 Do: CL 100 IL > () 80 X 60 IIJ CD LL 9 40 By ~ 20 LL A. AllWomen All Females, BeforeAge19 All Females, Before Age 16 O ~ ~ ~ 1971 1 976 SURVEY YEAR Black Females, B. Women by Race Before Age 19 0~ 1971 White Females, Before Age 19 _ Black Females, Before Age 16 White Females, Before Age 16 1 1 1 976 SURVEY YEAR 1 979 1 979 FIGURE 2-4 Percentages of (a) all young women and (b) young white women and young black women residing in metropolitan areas who reported premarital sexual intercourse prior to ages 16 and 19 in surveys conducted in 1971, 1976, and 1979. SOURCE: Zelnik (1983~.

100 ~ UNDERSTANDING SPREAD OF HIV 60 50 40 LL . G 30 20 10 O 1 1 1971 1 976 SURVEY YEAR 1 979 FIGURE 2-5 Percentage of sexually active young women ages 15-19 in the 1979 survey who reported more than one partner. Samples were restricted to women living in metropolitan areas. Error bars denote approximately one standard error around estimates. SOURCE: Zelnik (1983:Table 2-6~. and one third of the 19-year-olds were sexually inexperienced (i.e., had had no partners), a substantial fraction related having several sexual partners. For example, among the 19-year-oIcl women, 15 percent reported having 4 or more sexual partners and 3 percent reported 10 or more partners; for 17-year-olds, the reported numbers were considerably Tower, but 5 percent ciaimec! 7 or more partners. Comparing these data for young women born during the 1960s with the 1970 Kinsey Institute data on the number of premarital part- ners reported by women born during earlier periods of this century provides strong evidence that a major shift had occurred in the so- ciai norms governing nonmarital heterosexual sexual behavior among young women. Unmarried young men declared many more sexual partners than unmarried young women in these surveys. As Figure 2-6b shows, 7 percent of 17-year-oIcis, 24 percent of 19-year-olds, and 26 percent of 21-year-olds reported 10 or more partners. Even among 17-year- old males, more reported intercourse with 6 or more partners (20 percent) than reporter! only a single sexual partner (17 percent). Nonetheless, the modal response category for 17-year-old mates was no partners: 45 percent of the mate sample reported that they had not had intercourse prior to age 17.

SEXUAL BEHAVIORS ~ 101 60 50 <~ 40 of LLI On TV CC 20 10 o 50 40 Lo CO Jo 30 an LU O 20 0 o o ~ . _ _ o ~ Age 17 O Age 19 i A. Women _ [:~ ~ ~ ~ ~ 2 3 4 5 6 7-9 10+ NUMBER OF PREMARITAL SEX PARTNERS, FEMALES e] Age 17 Cal Age 19 Age 21 B. Men 5 6 7-9 1 10+ 2 3 4 NUMBER OF PREMARITAL SEX PARTNERS, MALES FIGURE 2-6 Number of premarital sexual partners reported by (a) young women at ages 17 and 19, and (b) young men at ages 17, 19, and 21. The survey sample was restricted to persons residing in metropolitan areas. SOURCE: Secondary analysis of 1979 survey of young men and women conducted by Kantner and Zelnik; see Zelnik (1983) for a description of the survey.

102 ~ UNDERSTANDING SPREAD OF HIV ADULT HETEROSEXUAL BEHAVIORS As was noted earlier, there is a dearth of reliable information on adult sexual behavior of all types. At a late stage in the committee's deliberations, it received preliminary findings from a project that had been conducted by the National Institute of Child Health and Human Development (NICHD) and the National Opinion Research Center (NORC) to develop a rigorous basis from which to infer patterns of sexual behavior in the adult population of the United States. The results of the preliminary stage of the program were reported briefly by Michael and colleagues (1988~; the committee receiver! a final data tape from this preliminary effort in October 1988, and we describe some findings in this section. Because of extreme time pressures, however, the committee's analyses of this data set have been restricted in scope. In addition to this new source of data, there is also some in- formation available from other recent commercial surveys. The in- tense interest in the AIDS epidemic prior to 1988 spawned a num- ber of opinion polls that asked questions related to AIDS and HTV transmission. The surveys were generally restricted to asking about knowledge and attitudes concerning AIDS, but a few asked explicit questions about sexual behaviors. Although such brief and quixotic forays into behavioral measurement do not ordinarily merit serious attention, some unique data have been obtained in at least one na- tional poll. Because of the paucity of information relevant to HIV transmission, the results of that survey are presented in some cletai! Respite the committee's reservations about the representativeness of the sample). The results of this poll supplement the early findings of the NICHD/N()RC effort. We begin by briefly reviewing the data collection methods used in the two surveys and then move to a consideration of the results they obtained. Where possible, we have sought to present both in- dividual and combined results from the surveys, although in some cases, this was simply not possible because the two surveys did not ask the same questions. The reader will also note that there are many important substantive areas about which there are simply no data from these or any other reliable sources. For example, although both surveys provide data on the number of sexual partners reported by respondents during the previous 12 months, no information is available on the frequency of sexual activity with different partners or the frequency of particular activities (e.g., anal intercourse) that may pose an elevatecl risk of HIV transmission. Moreover, there is

SEXUAL BEHAVIORS ~ 103 no direct information on the frequency of condom use (although one of the surveys does provide data on the frequency of condom pur- chases). Thus, even if the data provided from these surveys were flawlessly derived from large samples, there are substantial gaps in knowledge that seriously compromise our understanding of hetero- sexual behaviors in the U.S. population that have the potential to transmit HIV. Nevertheless, these data provide the rough beginnings of a body of urgently needed information on the sexual behavior of the U.S. population. Details of Survey Execution 1988 General Social Survey The General Social Survey, or GSS, the program conducted by NICHD/NORC, is an annual, full-probability sample survey of nonin- stitutionaTized American adults. Survey respondents are interviewee! in person for approximately one hour on a wide range of social and political topics (Davis and Smith, 1988~. The 1988 GSS interviewed 1,481 adults between February 14 and April 2S, 198S, obtaining a response rate of 77 percent. At the conclusion of the 1988 GSS, respondents were asked to complete a one-page self-adm~nistered questionnaire. The questionnaire asked about the number and gen- der of respondents' sexual partners during the past 12 months and their relationships with these partners. (A preliminary analysis of these data has been reported by Michael and colleagues t1988~.) Los Angeles Times Survey In July 1987, 2,095 adults were interviewee! from a sample that had been clesignecT as a probability sample of telephone-owning house- holds. The survey design incorporates! both a national sample and an oversampling of the five cities reporting the greatest numbers of AIDS cases (Los Angeles, Miami, New York City, Newark, and San Francisco). Because of a Tow response rate,l5 the estimates procluce<1 from the survey cannot confidently be projected to the entire adult population 15For the entire survey (i.e., 1,208 cases in the national sample and 887 cases in the five-city oversample), we calculated a 33 percent response rate (using a procedure that conforms to the guidelines adopted by the Council of American Survey Research Orga- nizations). However, because the survey drew an 887-case oversample from five urban areas (New York, Newark, Los Angeles, San Francisco, and Miami) in which response rates are traditionally much lower, we believe the effective response rate for the national sample (excluding the oversample) was actually higher than 33 percent. Unfortunately,

104 ~ UNDERSTANDING SPREAD OF HIV of the United States. Rather, the survey results are reflective of a portion of that population: those (one third to one half of aclults) who can be reached by telephone (within three call-backs) and who will consent to being interviewed by telephone in what is described as a "public opinion survey" being conducted by a newspaper. It should be noted, however, that most of the nonresponse in this survey was apparently unrelated to the survey's content. The overwhelming majority of persons who refused to be interviewed did so during the household screening (1,279 of the 1,471 refusals), before being asked questions on AIDS or on sexual behaviors. Turner and coworkers (in press:Table 1) report that the clemo- graphic characteristics of respondents in this survey agree roughly with Census Bureau estimates of the age and marital status dis- tributions of the national aclult population; there is some under- representation of men and blacks, however, and a more substantial underrepresentation of persons with less than a high school educa- tion. 16 The questions asked in the survey elicited information on the following: . number of sexual partners during the past year, . frequency of condom purchases during the past year, precautions taken against AIDS, . estimates of personal risk of contracting AIDS, and . knowledge about the ways in which AIDS is transmitted ant! attitudes toward various AIDS-related social poli- cies (e.g., school attendance by children with AIDS). Survey Results Both surveys asked respondents a question about the number of their sexual partners during the past yearly The responses to this question yielded a number of interesting results. Table 2-3 clisplays the Los Angeles Times survey organization could not easily provide information on response rates for different sample strata. 16Bias in the education distribution is a well-known deficiency of samples obtained by many commercial and academic telephone surveys (see Turner and Martin, 1984:Vol. 1, Figure 3.1~. In the substantive analysis reported by Turner and colleagues (in press) and in the committee's analysis in this chapter, weights encoded in the data set by the survey organization have been used in all tabulations. These weights incorporate adjustments to provide a better match to Census demographics (see Turner et al., in press:Table 1~. 17The questions posed to respondents were: "About how many sexual partners would you say you have had in the last year?" (L.A. Times); and "How many sex partners have you had in the last 12 months?" (NORC).

SEXUAL BEHAVIORS | 105 the results obtained in both surveys, collapsing (for the moment) the top category to three or more partners. This table also presents the overall estimates (and stanciard errors) derived by combining the two sets of data and estimating a mode! of the table that fits the 4-way marginal (partners by age by marital status by gender. The combiner! results of the two surveys indicate several findings of interest. . Among unmarried men and women aged 18-24, only 19 percent of women ant! 16 percent of men reported that they had been without a sexual partner during the entire year. . Forty percent of unmarried men and 15 percent of unmarried women aged 18-24 reported three or more partners in the pre- ceding 12 months. . For unmarried! men, the percentage reporting three or more partners declined with age (although the trends varied between surveys). Even among men aged 65 years and older, however, approximately 4 percent reported three or more sexual partners. In both surveys, no woman in this age group reported more than one sexual partner Luring the preceding year. . Approximately 1 percent of unmarried women and 6 percent of unmarried men reported nine or more partners during the previous year. Because the survey did not obtain information on the gender of partners, it is impossible to separate heterosexual and homosexual partnerships. . Roughly 4 to 6 percent of married men, aged 25-49, reported two or more sexual partners during the preceding 12 months. 18Using a stratified jackknife procedure (Fay, 1982) to fit a hierarchical series of log- linear models to the 5-way table, we found that a model that fit the {PAGM} and {AGMS} marginals (where P = partners, A = age, M = marital status, G = gender, and S = survey) could be improved slightly by also constraining the model to fit the {PS} marginal (jackknifed likelihood-ratio chi-square for comparison of two alternate models: J2 = 1.49, d.f. = 3, p = .051~. This improvement is of borderline statistical "significance." An examination of estimates of the APS parameters for this "improved" model indicates that the observed intersurvey discrepancy was largely attributable to minor variations between the surveys in the numbers of persons with no sexual partners and with one partner. Estimates of the APS parameters (and standard errors) for a log- linear model constrained to fit {PAGM} {SAGM} {PS} were .127 We. = .070) for zero partners; - .123 (.063) for one partner; .035 (.073) for two partners; and—.040 (.072) for the category three or more partners. (Model parameters are "arbitrarily] coded so that positive values indicate an "excess" of NORC cases in the specified category.) With the effects of weighting and the complex sample design in the range of deff = 1.6, significant effects were not found for other multivariate parameters involving P and S (e.g., {PAS}, {PGS}, {PMS}, etch. It should be noted that all model comparisons fit the {SAGM} marginals, which allows for intersurvey differences in the demographic composition of the samples drawn by the two surveys.

106 ~ UNDERSTANDING SPREAD OF HIV TABLE 2-3 Number of Sexual Partners in the Last Year by Gender, Marital Status, and Age from the 1987 Telephone Survey Conducted by the Los Angeles Times (LAT) and the 1988 Personal Interview Survey Conducted by the National Opinion Research Center (NORC) Number of Sexual Partners in Last Year None 1 2 3+ Total (N) Unmarried men 18-24 LAT 14.1% 38.6% 8.7% 38.6% 100% (83) NORC 19.6 24.0 12.8- 43.6 100 (68) Comb. fit 16.5 32.3 10.5 40.7 100 (151) (s.e.) (4.8) (5.9) (3.5) (5 8) 25-34 LAT 8.1 61.3 8.1 22.5 100 (99) NORC 17.9 41.9 7.7 32.5 100 (63) Comb. fit 12.4 52.9 7.9 26.9 100 (162) (s.e.) (3~7) (6 4) (2~3) (4.5) 35-49 LAT 3.7 34.3 22.2 39.9 100 (64) NORC 20.3 44~3 15.2 20.3 100 (59) Comb. fit 13.5 39.7 18.2 28.5 100 (123) (s.e.) (4 8) (6 3) (4.0) (5.4) 50-64 LAT 13.9 44.4 6.3 35.4 100 (43) NORC 50.0 30.8 11.5 7.7 100 (21) Comb. fit 22.3 41.3 7.5 29.0 100 (64) (s.e.) (5~8) (11 3) (3.6) (9.0) 65+ LAT 80.0 12.2 5.5 2.3 100 (37) NORC 61.1 27.8 2.8 8.3 100 (30) Comb. fit 74.0 17.2 4.6 4.2 100 (67) (s.e.) (6 4) (5.3) (3.0) (2.1) Unmarried women 18-24 LAT 16.3 56.1 10.4 17.3 100 (112) NORC 23.5 47.9 16.8 11.8 100 (50) Comb. fit 19.0 52.8 12.7 15.5 100 (162) (s.e.) (3.9) (5.9) (4~1) (5 1) 25-34 LAT 17.7 69.2 10.6 2.5 100 (108) NORC 9.1 62.2 16.1 12.6 100 (90) Comb. fit 13.2 65.3 13.6 7.9 100 (198) (s.e.) (3~2) (4.8) (3.1) (2.4) 35-49 LAT 23.5 57.9 12.0 6.6 100 (107) NORC 27.5 51.9 12.2 8.4 100 (94) Comb. fit 25.5 54.9 12.1 7.5 100 (201) (s.e.) (4 3) (4~8) (3.7) (2.4) 50-64 LAT 52.8 32.5 12.8 1.9 100 (85) NORC 69.0 25.0 6.0 0.0 100 (60) Comb. fit 60.2 29.9 8.8 1.2 100 (145) (s.e.) (5~6) (5.5) (3.8) (0.8) 65+ LAT 92.7 7.3 0.0 0.0 100 (114) NORC 95.0 5.0 0.0 0.0 100 (114) Comb. fit 93.7 6.3 0.0 0.0 100 (228) (s.e.) (1~7) (1 7) (0.0) (0.0) Continued

SEXUAL BEHAVIORS ~ 107 TABLE 2-3 Continued Number of Sexual Partners in Last Year None 1 2 3+ Total (N) Married men 18-24 LAT 0.0 % 84.3 % 3.2 % 12.5 % 100 % (22) NORC 0.0 80.8 0.0 19.2 100 (13) Comb. fit 0.0 83.6 2.5 13.9 100 (35) (s.e.) (0-0) (9.1) (2.5) (9.2) 25-34 LAT 0.1 92.6 2.1 5.2 100 (127) NORC 2.8 93.1 2.8 1.4 100 (72) Comb. fit 1.0 92.7 2.3 4.0 100 (199) (s.e.) (0 6) (2~9) (1.2) (2~4) 35-49 LAT 4.1 92.0 0~0 3.8 100 (190) NORC 5.1 89.1 3.6 2.2 100 (129) Comb. fit 4.6 90.7 1.7 3.1 100 (319) (s.e.) (1.7) (2.0) (0.7) (1.2) 50-64 LAT 3.4 94.9 0.6 1.1 100 (91) NORC 10.9 85.5 1.2 2.4 100 (74) Comb. fit 5.9 91.7 0.9 1.6 100 (165) (s.e.) (2~0) (2 3) (0.6) (0.8) 65 + LAT 11.4 83.4 4.0 1.2 100 (64) NORC 25.5 71.5 0.0 2.9 100 (68) Comb. fit 17.3 78.4 2.3 1.9 100 (132) (s.e.) (3-0) (4~8) (2.3) (1.0) Married women 18-24 LAT 2.6 97.4 0.0 0~0 100 (44) NORC 0.0 86.6 10.4 3.0 100 (32) Comb. fit 1.7 93.6 3.7 1.0 100 (76) (s.e.) (1~7) (2~9) (2.1) (1.1) 25-34 LAT 0.1 97.9 2.0 0.1 100 (156) NORC 1.1 97.8 0.0 1.1 100 (87) Comb. fit 0.5 97.8 1.2 0.s 100 (243) (s.e.) (0.5) (1.2) (0.9) (0.5) 35-49 LAT 3.4 92.6 0.7 3.3 100 (235) NORC 3.5 96.5 0.0 0.0 100 (125) Comb. fit 3.5 94.2 0.4 1.9 100 (360) (s.e.) (1~5) (1.8) (0.2) (1.1) 50-64 LAT 17.5 82.5 0.0 0.0 100 (125) NORC 14.5 83.7 0.6 1.2 100 (78) Comb. fit 16.3 83.0 0.2 0.5 100 (203) (s.e.) (5~2) (5~2) (0.2) (0.5) 65 + LAT 15.9 84.0 0.1 0.0 100 (66) NORC 29.0 69.4 0.0 1.6 100 (61) Comb. fit 21.7 77.5 0.1 0.7 100 (127) (s.e.) (4~2) (4~2) (0.1) (0.7) NOTE: Percentage distributions for the Los Angeles Times data set were calculated using weights encoded in the data set by the survey organization. Sample sizes shown are un- weighted Ns. NORC percentages are calculated from weighted tabulations. Combined fit esti- mates and standard errors were derived using procedures of Fay (1982) to take account of complex sample design and sample weighting. (Weights in each survey were normalized so that the weighted N for each survey equaled the unweighted case count.) Question Wordings. Los Angeles Times: "About how many sexual partners would you say you have had in the last year?" NORC: "How many sex partners have you had in the last 12 months?"

108 ~ UNDERSTANDING SPREAD OF HIV . Approximately 1 to 2 percent of married women in this age range reported two or more sexual partners. Of unmarried persons who described themselves as "strongly religious" Christians in the Los Angeles Times survey, 66 percent of men and 40 percent of women reported at least one sexual partner in the past year; 26 percent of men and 12 percent of women in this group reported two or more partners over the past 12 months (Turner et al., in press:Table 2~. The data from these surveys also contain anomalies that begin to suggest the difficulties of conducting rigorous research on human sexual behaviors. For example, nontrivial proportions of married respondents reported that they had no sexual partners cluring the preceding year. For some, this may, indeecl, be a true statement, and the increase in these proportions with age supports this view. It is also possible, however, that some respondents may not consider their spouses to be "sexual partners" one example of the many possible ways in which the language and frames of reference researchers and respondents bring to a survey may differ. These differences can have important implications for the interpretation of the resultant data, and they mandate careful pretesting and pilot work for those who would use surveys to learn about sexual behavior in the population. Condom Use and Risk Perception Given the high level of awareness in the United States that HIV can be transmitted sexually, condom purchases by persons reporting a large number of sexual partners during the preceding year are of particular interest. In an analysis of the Los Angeles Times data set,~9 Turner and colleagues (in press) found that, even though frequency of condom purchases increased with the number of sexual partners (for both men and women), 45 percent of the men reporting nine or more partners during the past year and 65 percent of the women reporting three or more partners stated that they had never purchased condoms during the past year. Although it is possible that condoms were used without being purchased (e.g., they were supplied by the other partner) or that other low-risk sexual practices were employed, this result suggests that sexual intercourse without protection against HIV transmission may be fairly common, even among people who have a large number of sexual partners. i9The 1988 GSS did not ask respondents about condom use.

SEXUAL BEHAVIORS ~ 109 Substantial proportions of those in the Los Angeles Times sam- ple who reported many sexual partners also believed they were not at risk of contracting AIDS. Thus, when respondents ratecl their risk of contracting AIDS on a scale of 1 to 7 (with 1 representing the lowest possible risk and 7 the highest), the majority of those with nine or more sexual partners chose the lowest level (Turner et al., in press:Table 4~. Even in urban areas that have experienced the great- est number of AIDS cases (i.e., New York, Newark, San Fiancisco, Los Angeles, and Miami), almost one half of the respondents with nine or more partners assessed their risk of contracting AIDS at the lowest level offerec3.2° As these analyses begin to suggest, the psychological and social processes that underlie sexual behaviors are complex. Indeed, as Chapter 5 discusses, this complexity poses substantial challenges for the design and implementation of interventions clesigned to facilitate change in risk-associated sexual behavior (e.g., by decreasing the frequency of sexual behaviors that carry a high risk of transmitting HIV and other sexually transmitted infections). Special Studies In addition to the two national studies of aclult heterosexual behav- ior, we discuss below two other research efforts that offer important insights. One of these (Blumstein and Schwartz, 1983) provides com- parative information on heterosexual, gay, and lesbian couples. Al- though this study uses a nonprobability sample, its conclusions are of interest, even though its numerical results cannot be generalized with known margins of sampling error to the population of heterosexual, gay, and lesbian couples. The second research project (Wyatt, l98Sa) studied relatively small samples (Ns = 122 and 126, respectively) of white and AfrmAmerican women in Los Angeles County; this project is of particular value because it collected extensive ciata on sexual practices from a probability sample of Afro-American women a population for which there are few data. 20Turner and colleagues (in press) also found that high levels of condom use could not account for the optimistic risk assessments of many of these respondents. Thus, among persons reporting five or more sexual partners during the last 12 months, 30 percent of those who rated their risk as low (1 or 2) reported that they never purchased condoms and 25 percent reported only one to four purchases. Indeed, there was no significant association between condom purchasing and perceived risk among persons with five or more sexual partners.

110 ~ UNDERSTANDING SPREAD OF HIV Couples Study Data Between the spring of 1978 and late 1979, Blumstein and Schwartz (1983) mailecl self-administered questionnaires to a large number of couples, including married heterosexuals, cohabiting heterosexuals, gay mate couples, and lesbian couples. The majority of these couples requested the questionnaires as a result of hearing appeals for coop- eration by the investigators on television and reading reports about the study in the mass media; in the case of the gay mate and lesbian couples, people also requested questionnaires as a result of hearing about the study from others who hack participated. Some 22,000 questionnaires were mailed to the 11,000 couples who volunteered to participate in the study, and somewhat over one half of those to whom they were mailed returned the two questionnaires as required for inclusion in the study. Of the 7,397 married or cohabiting het- erosexual couples who requested questionnaires, 4,314 (58 percent) returned them, as dill 969 (52 percent) of the 1,875 gay mate cou- ples and 778 (46 percent) of the 1,723 lesbian couples who requested them. All of these volunteer couples completed a Tong (38 pages), self-administered questionnaire about various aspects of their rela- tionships, and these data provide the statistical base for the stucly. Of these cases, 320 (129 heterosexual, 98 gay male, and 93 lesbian couples) were purposively selected to be interviewed face to face. The couples were first interviewed apart and then as a couple; they were subsequently asked to solve some couple dilemmas without interview- ers present but with a tape recorder running. Finally, a subsample of those who filled out the self-administered questionnaire was mailed a shorter questionnaire 18 months after the interview to determine whether the relationship had remained intact. The response rate far this instrument ranged from 67 nernnnt. among cohahitors to 82 percent among married couples. ~ O The sample obtained by Blumstein and Schwartz was skewed in several ways. Although the researchers were seeking a "large and diverse sample of respondents" (Blumstein and Schwartz, 1983:15) that would reflect an array of values and life-styles, the mode of case gathering they used resulted in a case base that was 95 percent white, 85 percent college educated, and centered in three metropolitan re- gions (Seattle, San Ffancisco, and New York). The case gathering involved a number of stages of self-selection that seem likely to have produced systematic biases. Respondents had to be aware of appeals made in the mass media, to write for questionnaires, and to fill out

SEXUAL BEHAVIORS ~ Ill (with the partner's knowlecige), a long instrument about intimate topics, a task that required substantial literacy and attention. The published ciata from the study focus on the roles of money, work, and sexuality in coupled relationships, exploring differences among couple types. The ciata on sexuality do not differ a great clear from the data gathered by other studies of volunteer popula- tions in which the findings are based on the reports of individuals. Sexual frequency differecl among the various types of couples and was patterned in different ways, depending on the duration of the relationship. Married couples were having sex at least once a week, and rates Tower than once a month among these couples were rare. However, the rates these couples reported were higher than those of most sampled populations and may represent the volunteer bias of the study. Cohabitor couples had sex more often than married couples, but the cohabitors were also comparatively younger with shorter durations of living together. The pattern for gay men was similar to those found in other studies: much higher rates of sexual activity early in relationships but much lower rates later on. Lesbians reported far less sex in their relationships than cTid the other groups. Patterns of sexuality outside of the couples followed at least a ranking pattern that is similar to other studies: 26 percent of married hetero- sexual men, 21 percent of married heterosexual women, 33 percent of mate cohabitors, 30 percent of female cohabitors, 92 percent of gay men, and 28 percent of lesbians reported sexual relationships out- side of that of the primary couple. These differences in prevalence are reflected in numbers of partners as well (see Table 2-4~. The prevalence figures for heterosexual men are somewhat lower than might have been expected from other similar data sources, but the requirement that both persons participate in the stubbly might have reduced these numbers. Differences in the duration of relationships also affected these rates: the longer the relationship, the greater the prevalence of sexuality outside the couple relationship and the larger the number of partners. As noted earlier, however, it is important to interpret these figures cautiously. The numerical estimates from this study cannot be confidently generalized to the population at large because the survey used a convenience sample. White and Afro-American Women in L'os Angeles In a series of papers, Wyatt and her collaborators have reported on the sexual experiences of 126 Afro-American and 122 white women residing in Los Angeles County. The study (Wyatt, 1985:508-510)

UNDERSTANDING SPREAD OF HIV TABLE 2-4 Number of Outside Sexual Partners During Relationship Number of Sexual Partners Group 0 1 2-5 6-20 20 + Na Husbands 74% 8% 11 % 6% 2% 3,591 (913) Wives 79 9 8 3 1 3,606 (750) Male cohabitors 67 12 16 4 1 634 (210) Female cohabitors 70 13 12 4 0 639 (197) Gay men 18 6 16 25 35 1,914 (1,513) Lesbians 72 15 12 1 0 - 1,554 (368) NOTE: As described in the text, these distributions cannot be generalized to the national pop- ulation because the study was based on a convenience sample of couples. aTotal N is the number of individuals who reported any instances of nonmonogamy since the beginning of the relationship; the parenthetical N its the number of individuals who reported how many sexual partners they had outside the relationship. The percentage distribution for the numbers of partners is calculated on the percentage of respondents who reported nonmonogamy. SOURCE: Blumstein and Schwartz (1983). enlisted women aged 18-36 using a telephone survey to recruit suit- able probability samples. The sample of white women was matched to the sample of Afro-American women on education, marital status, and the presence of children in the household (Wyatt, l98Sb:15~. All respondents were subsequently interviewed in person at a location of their choice. The interviews, which were usually conducted in two sessions, covered a broad range of topics. The women's sexual histories were obtained using a 478-item structured interview whose topics included sources of sexual education; onset, frequency, and cir- cumstances of various sexual behaviors; frequency and circumstances of any sexual abuse during childhood or adolescence, consequences of sexual abuse; experiences of sexual harassment in school work, or social settings; and sex role stereotypes. The total interview time ranged from three to eight hours, depending on the woman's sexual experiences. The refusal rate for the survey was 45 percent (includ- ing women who refused to schedule an interview and women who terminated the telephone recruitment before their eligibility could be cleterminecI).2i 2iWyatt (1985:509) reported identifying 1,348 households in which a woman resided. Of these, 709 women met the study's inclusion criteria and agreed to be interviewed, 266 met the inclusion criteria and refused to be interviewed, and 335 women terminated

SEXUAL BEHAVIORS ~ 113 Wyatt (l98Sa:9-11) has reported several findings of interest from this study: . 39 percent of white women ancT 48 percent of Afro- American women in this study reporter! that their first experience of sexual intercourse occurred at or before age 16; . 74 percent of white women ancT 26 percent of Afro- American women reporter! 13 or more sexual partners since age 18; . 43 percent of white women anc} 21 percent of Afro- American women reported some experience with anal intercourse; ancT 5-6 percent of each sample reporter] engaging in anal in- tercourse on a regular basis (one or more times a month). These ciata suggest, as clo the findings of the two national surveys, that there is a sexually active subset of the aclult population (that in- clucles both whites anti Afro-Americans) that engages in heterosexual behaviors that may carry a significant risk of HTV transmission. TRENDS IN SEXUAL BEHAVIOR AMONG PERSONS OF THE SAME GENDER The stucly of sexual conduct among persons of the same gentler— referrer! to as homosexuality by some ancT as the sexuality of gay men ancT lesbians by others has a number of dimensions that are clirectly relevant to the AIDS epidemic and to the sexual transmission of HTV. Key aspects of same-gencler sexual behavior inclucle . the number of persons who have sex with persons of the same gentler; . the frequency of such contacts ancT the number of part- · · — ners in various perloc s; . the sexual techniques used in sexual encounters; . the number of sexual partners who are of the opposite gentler; anc! . the social characteristics of the inclividual ancT of his or her sexual partners (i.e., the personal sexual network of an incTiviclual). the telephone recruitment interview before it could be determined whether they met the study's inclusion criteria.

114 ~ UNDERSTANDING SPREAD OF HIV Equally important to an understanding of behavior is setting these variables into the changing cultural, historical, and social cir- cumstances of sexual conduct with persons of the same gender over the last four decades in the United States. This context is important for an understanding of the complexity of same-gender sexuality, the variety of ways in which it is expressed, and the willingness of dif- ferent indivicluals and groups who have sexual partners of the same gender to adopt safer sex practices. Finally, it is important to rec- ognize that the terms used to describe sexual activity among people of the same gender are culturally and politically significant. That is why we have often chosen to use the term same-gender sexual conduct and its variants rather than homosexuality or gay men and lesbians, except when such terms are historically or culturally appropriate. The Kinsey Research The general challenge that Kinsey and the Kinsey reports posed to widely held beliefs about sexuality has been discussed earlier in this chapter. It was in the area of what happened sexually between men and men and between women and women, however, that Kinsey's work most clearly cliverged from prior scientific and moral perspec- tives. This divergence occurred in both the survey's empirical find- ings and in the explanation of those findings. In his studies, Kinsey found that a far larger number of people than expected reported that they had had sex with persons of the same gender. Kinsey's conception of the relation between sexual activity among persons of the same gender and sexual activity with persons of the other gender also differed quite markedly from earlier research. Prior to the Kinsey studies and in the period during which they were being conducted! persons who had sex with persons of the same gender were in nearly universal danger of social ostracism of the most severe kinds: criminal prosecution and imprisonment, coerced psy- chotherapy, blackmail, robbery, and victimization by the criminal justice system.22 Anyone who was attracted sexually or emotion- ally to persons of the same gender and acimittec3 this fact to others was treated as perverse or deviant. Even those who kept their sexual 22Gagnon and Simon (1973) summarize Kinsey's data on the experiences of men with extensive homosexual histories and with histories of robbery, blackmail, and troubles with the police. Weinberg and Williams (1974) present data on men who experienced trouble in military and civilian life prior to the 1970s, and Kinsey and coworkers (1948) discuss the legal difficulties of men with homosexual experience. Chapter 7 (Figure 7-2) presents contemporary survey data on public prejudice against same-gender sexual experience.

SEXUAL BEHAVIORS ~ 115 preferences to themselves often experienced severe psychological con- flicts. In general, it was believed that the negative psychological and social situations that characterized the lives of persons who were "ho- mosexual" were a simple consequence of their moral or psychological defects rather than the result of social persecution and oppression uncler which they acquired and expressed their sexual clesires. Kinsey (e.g., Kinsey et al., 1948:616-617) opposed the theoretical belief, which was well established among psychiatrists and psychoan- alysts, that persons with substantial amounts of same-gencler sexual experience constituted a discrete category of persons whose lives were entirely governed or at least strongly influenced by this sexual prefer- ence (Freud, 1905; Bergler, 1956~. This conception was very close to the prior folk belief, shared by both "heterosexuals" and "homosex- uals," that "homosexuality" was groun(led in a gender defect (either constitutional or learned. Homosexual men were somehow insuffi- ciently masculine (and therefore effeminate), and homosexual women were insufficiently feminine (and therefore mascuTine). More compli- catecT explanations were formulatecI, but at the center of the theory was the belief that there existed a class of persons whose conduct depended on common pathological origins (Socarides, 1978~. From this perspective, there must be a profound psychological or biological division between heterosexuals and homosexuals; consequently, the former were treated as essentially normal and the latter as essentially abnormal. Kinsey attacked this dichotomy on two levels: sexual theory and indiviclual experience. On the basis of theory, he argued against ho- mosexuaTity as a discrete social, moral, or psychological "type." He proposed that the relation between heterosexuality and homosexual- ity be treated as a continuum rather than two discrete categories, and he argued that sexuality could best be understood through the pro- portion of other-gender ant! same-gencler sexual acts (ancT fantasies) in which individuals engaged. Kinsey based his view on a distinc- tion he saw between the biological diversity found in unmanaged nature and the limitations on diversity found in civilized societies based on agriculture. Translating this concept into the sexual arena, a contrast was created between the sexual bounty of the natural world and Western cultural selection for a monocrop of procreative heterosexuality. Thus, Kinsey and his coworkers wrote: Males do not represent two discrete populations, heterosexual and homosexual. The world is not to be divided into sheep and goats. Not all things are black nor all things white. It is a fundamental of taxonomy that nature rarely deals with discrete categories.

116 ~ UNDERSTANDING SPREAD OF HIV Only the human mind invents categories and tries to force facts into separated pigeon-holes. The living world is a continuum in each and every one of its aspects. The sooner we learn this concerning human sexual behavior the sooner we shall reach a sound understanding of the realities of sex. (1948:639) That continua-are as much human inventions as dichotomies, and that there is, for certain purposes, a need to distinguish between sheep and goats, are reasonable intellectual responses to Kinsey's view. The important points, however, are Kinsey's decision to make heterosexuality and homosexuality a question of acts rather than of common pathological origins and his proposal of a continuum within which an individuals position can fluctuate over the life course. To measure an individuaT's position on this continuum from het- erosexuaTity to homosexuality, Kinsey developed the H-H (or 0-6) scale. Interviewers collected a record of a person's experiences and psychic reactions during the sex history portion of the interview and, on returning from the field, counted up necessarily in some- what crude ways the frequency of sociosexual experiences, with and without orgasm, with partners of the same or different genders (in- depenclent of marital status and other factors). The proportion of same-gender experiences was used to place the interviewee on the H-H scale. In addition, estimates were made of the ilequency of sexual dreams with and without orgasm and the proportion of mas- turbation that could be cIassifiec3 as having same-gender or other- gender content. These calculations were less precise than those from sociosexual experience, most significantly because of the weaker at- tention that was given to fantasy in the interviews. The counts were made for each year of life and then were addecl together to produce totals both for the life span ant! for various life periods. There was a good deal of judgment involved in the assignment of scale scores, and the Kinsey researchers often estimated the "importance" of different kincis of sexual activity when assessing their contribution to the final scale number chosen. By focusing on acts rather than on persons, Kinsey argued that there is no such thing as a homosexual person, only persons with various mixtures of acts. He did not, however, actually propose a specific theory of the acquisition, maintenance, or transformation of either heterosexuality or homosexuality in his 1948 volume. The closest he came was to argue: If all persons with any trace of homosexual history, or those who were predominantly homosexual, were eliminated from the pop- ulation today, there is no reason for believing that the incidence of the homosexual in the next generation would be materially

SEXUAL BEHAVIORS ~ 117 reduced. The homosexual has been a significant part of human sexual activity ever since the dawn of history, primarily because it is an expression of capacities that are basic in the human animal. (Kinsey et al., 1948:666; emphasis added) Later, in the volume on women, and largely in response to critics of this argument, Kinsey wrote: The data indicate that the factors leading to homosexual behav- ior are (1) the basic physiologic capacity of every mammal to respond to any sufficient stimulus; (2) the accident which leads an individual into his or her first sexual experience with a person of the same sex; (3) the conditioning effects of such an experience; and (4) the indirect but powerful conditioning which the opinions of other persons and the social codes may have on an individual's decision to accept or reject this type of sexual contact. (Kinsey et al., 1953:447) The grudging readmission of what is at least a stripped-down version of the roles of psychology and culture in sexual life is an important shift, one that is characteristic of a change in Kinsey's views as he writes about female rather than male sexuality (Gagnon, 1978). What is problematic for Kinsey's view of people as embodying a mixture of sexual acts is that at the time Kinsey's work was be- ing published, most individuals with same-gender sexual experiences actually lived in terms of the social types Kinsey fought so hard to dissolve. Persons with same-gender sexual experiences often viewed themselves ant! were viewed by others, whether hostile or friendly, as enacting or resisting the social roles provided in the homosex- ual culture of the day: "sissy," "queer," "(tyke," "fem." "hutch," "trade," anal "faggot" were experienced as significant cultural labels. On the other hand, Kinsey's theoretical arguments were given addi- tional power by the sheer number of persons in his collection of cases who reported at least some sex with persons of the same gender. In addition, both his supporters and critics considered} the number of persons who hac! reported same-gender sexual experience to be generalizable to the larger population. As was argued earlier, there is no scientific basis for accepting such a generalization, but because Kinsey provides the earliest figures in this area and because these figures have been used as bases for national estimates, they need to be discussed. In Sexual Behavior in the Human Mate, Kinsey and his colleagues reported that . . . 37 per cent of the total male population has at least some overt homosexual experience to the point of orgasm between adolescence

118 ~ UNDERSTANDING SPREAD OF HIV and old age . . . 10 per cent of the males are more or less exclusively homosexual (i.e., rate 5 or 6) for at least three years between the ages of 16 and 55.... 8 per cent of the males are exclusively homosexual (i.e., rate a 6) for at least three years between the ages of 16 and 55.... 4 per cent of the white males are exclusively homosexual throughout their lives, after the onset of adolescence. (1948:650-651; all emphases in the original; the numbers 5 and 6 refer to Kinsey's 0-6 H-H scale noted previously) There is reason to be cautious about these figures, even when they are not being used to create national estimates. The chapter in the 1948 report on mate homosexual behavior was based on 4,301 cases, a group that included a substantial number of persons with current or prior prison experience. The inclusion of large numbers of prisoners biased the resulting figures. Analyzing only the col- lege attenders in the Kinsey collection of cases, Gagnon and Simon (1973:131) found that tiin a reanalysis of the cases of 2,900 young men who were in college between the years 1938 and 1950, the bulk of whom were under thirty at the time they were interviewed, 30 percent had undergone at least one homosexual experience in which either the interviewee or his male partner was stimulated to the point of orgasm (note that this differs from the Kinsey definition). Of these 30 percent, however, slightly more than one-half (16% of the total) had shared no such experiences since the age of fifteen, and an additional third (970 of the total) had experienced all of their homosexual acts during adolescence or incidentally in the years before they reached the age of twenty. Thus, for 25 percent of all males who were interviewed, homosexual experience was confined predominantly to adolescence or to isolated experiences in the later adjacent years. The remaining 5 to 6 percent are divided into those men who had only homosexual experiences, comprising some 3% of the 2,900, and the remaining 3~o who had substantial homosexual histories as well as heterosexual histories. Although these figures may offer some insight, they cannot re- place data that have been collected! from more carefully sampled and equally well-interviewec3 populations. What this and other reanalyses of the Kinsey data have in common, however, is that the estimates they provide of the extent of male homosexual experience are Tower than those of Kinsey. From Kinsey to the AIDS Epidemic The Kinsey research findings on same-gender sexuality generated a number of responses in the period from 1955 to 1975. The appeal for understancling and tolerance that was implicit in his scientific views had an effect among several groups interested in the reform of sexual

SEXUAL BEHAVIORS ~ 119 laws. The empirical findings that there were many persons with same-gender sexual lives and the public discussion of the existence of "homosexuality" were taken up by the emergent social and political groups among homosexuals who were campaigning for legal reform and social tolerance (e.g., the Mattachine Society and the Daughters of Bilitis, as well as other, more transitory groups). Slow changes in the actual social and living conditions of persons with same-gender sexual desires and experiences were accompanied by an increase in research interest among social psychologists and sociologists. Following a line of work initiated by sociological criminologists and later continued by labeling theorists who took for granted the social reality of cultural labels and their consequences, a small num- ber of ethnographic studies of homosexual communities were un- clertaken in the 1950s and 1960s (e.g., Leznoff and WestIey, 1956; Hooker, 1966~. Although often influenced by Kinsey, these studies moved away from traditional questions of etiology and focused on is- sues of life careers and adjustment and of psychological identity and culture among men and women living in same-gender subcultures. They found extraordinary variety. Although the men ant! women that made up these same-gender subcultures were participating in a common cultural community, they die! not appear to have common attributes. As a result, researchers were moved to understand these people not in terms of some common set of psychological character- istics but in terms of their social and cultural origins. In the late 1960s a critique of traditional etiologic and psychiatric studies (Si- mon and Gagnon, 1967; Gagnon and Simon, 1973) included several · . mayor points. There was no evidence that same-gencler sexual pref- erences were acquired through special or pathological pathways. There was also no evidence of special or fre- quent pathology among persons with such preferences that could not be explained by social oppression dur- ing the acquisition of and performance of same-gender sexuality. The issue of the origins of same-gender sexual prefer- ence was overemphasized and extremely difficult, if not impossible, to resolve, given that adult research sub- jects could offer only retrospective reports that were of- ten compromised by strong cultural pressures to adopt dominant theories of origins or development. Same-gender sexual conduct varied substantially accord- ing to the current circumstances of the subcommunity

120 ~ UNDERSTANDING SPREAD OF HIV . in which persons with such preferences participated and the relation of that subcommunity (especially relations involving sexual oppression) to the larger community in which it was embedded. The primary focus of research should be the condi- tions of social life among those with same-gencler sexual preferences, rather than the differences between same- gender and other-gender sexuality. The nonsexual aspects of such persons' life-styles were often more important in shaping their sexual lives than vice versa. Historical changes in societal tolerance of same-gender sex would be of consequence for the social and psycho- Togical adjustment of persons with same-gender sexual desires and experience. More generally, it was argued that the sexual life course was relatively discontinuous and that alterations in what appeared to be stable adjustments, including gender preference in sexual partners, were frequent, if not com- mon. Although agreement was never total on all of these positions among all researchers (e.g., Diamond, 1977; PilIard et al., 1981; Green, 1987), there was substantial movement of the majority of researchers toward a research program built on these ideas. Nevertheless, biases toward constructing a common "homosexual personality" remained common in psychological circles until strongly challenged in the 1970s (Morin, 1977~. Several major studies in the traditionofpsychopathologycompared"convenience"(nonprobabil- ity) samples of heterosexuals and homosexuals (Bieber et al., 1965; Saghir ant! Robins, 1973~. By 1973, however, the psychiatric defini- tions had changed, and same-gender sexuality was no longer taken as prima facie evidence of psychopathology (American Psychiatric Association, 1973; see also the discussion by Bayer, 1987~. The early small studies were followed by two others, funded by the National Institute of Mental Health, that interviewee! larger samples from Chicago during 1967-1968 (Gagnon and Simon, 1973) and from San Francisco cluring 1970-1972 (A. P. Bell and Weinberg, 1978~. The Chicago study interviewed 457 white men; the San Ffan- cisco study interviewed more than 900 individuals with same-gender sexual preferences plus a group of controls. Both stucTies sufferer! from the defect of using convenience samples of people who were sufficiently open about their sexual preferences to be available to

SEXUAL BEHAVIORS ~ 121 TABLE 2-5 Number of Sexual Partners of the Same Sex Reported During Lifetime by Homosexual Respondents Homosexual Respondents Number of Homosexual White Black White Black Partners Ever Males Males Females Females 1 0% 0% 3% 5% 2 0 .0 9 5 3-4 1 2 15 14 5-9 2 4 31 30 10-14 3 5 16 9 15-24 3 6 10 16 25-49 8 6 8 11 50-99 9 18 5 8 100-249 15 15 1 2 250-499 17 11 1 2 500-999 15 14 0 0 1,000 or more 28 19 0 0 N 574 111 227 64 SOURCE: Bell and Weinberg (1978:308). researchers. Indeed, only one study in this period studied men who were having sex with other men but who did not participate in the gay community by. Humphreys, 1970~. These studies confirmed what earlier research had inclicated: there was wide (liversity among members of the gay community in both social background and patterns of social and sexual conduct. Of particular relevance in the San Francisco study were the patterns of coupling fount! in these communities and the importance of coupled and affectional relations to both gay men and gay women. The patterns of sexual practices clid not differ a great deal from the Kinsey period, but there was some evidence of larger numbers of sexual partners in the groups that were recruited exclusively from the homosexual community itself (Table 2-5~. The studies also documented the importance of social networks for psychological adjustment and the importance of gender in struc- turing the (differences found between gay men anti lesbians. Again, there was no evidence of a specific set of etiologic origins for homo- sexuality or for a singular personality type among male or female homosexuals (A. P. Bell and Weinberg, 1978~. In a later publica- tion, however, A. P. Bell and colleagues (1981:216) hinted that these

122 ~ UNDERSTANDING SPREAD OF HIV data might suggest a possible biological propensity for same-gender sexuality: "tO]ur study provides no basis for rejecting biological ex- planations outright. It also suggests some more specific implications for the form which such explanations might take." However, these suggestions have proved to be controversial. 1970 Kinsey Institute Data on Same-Gencler Sexual Behavior About this same time (late 1960s, early 1970s), the National Institute of Mental Health also funded the Kinsey Institute study (described earlier), a national probability sample that included questions on same-gender sexuality. Although most of the data have not been published, limited permission was granted to conduct a secondary analysis of the data on same-gender sexual contact among men. A full report of these analyses has been published by Pay and colleagues (in press). Their analyses were complicate<] by missing information: approx- imately one quarter of the male respondents did not complete the items on same-gender sexual experiences. A procedure was devised for imputing missing values; Table 2-6 shows the resultant distribu- tion of reported plus imputes! same-gender sexual experiences in the male population by the age at which the last sexual contact took place. It was estimated that 3.3 percent of the adult male population in 1970 had such sexual contact after age 20 and that it occurred (during a specified period) either occasionally (1.9 percent) or fairly often (1.4 percent). When experiences at any age are included, it is estimated that 5.5 percent hacT some period in their lives when same-gender sexual contact occurred "occasionally" and 2.9 percent hacT such experiences "fairly often." There are significant differences, as would be expected, between the reported adult same-gender experiences of men who marry and men who remain unmarried (see Table 2-7~. Men who were 30 years of age or older at the time of the 1970 survey and who had never married were two to three times more likely than currently married men to report homosexual contacts after age 20 and also to have had a period in which the frequency of contact was "fairly often"; this category includes 3.5 percent of never-married men 30 years of age or older, 1.2 percent of currently marries! men, 1.7 percent of formerly married men, and 2.4 percent of single men 21-29 years of age. While there is greater prevalence of same-gender experience among never-married men, these estimates suggest that from 1 to 2

SEXUAL BEHAVIORS ~ 123 TABLE 2-6 Estimates of Percentage of Adult Male Population with Any Homosexual Experience, by Age at Last Contact and Frequency of Contact Level of Activity (as percentage of total sample) Age at Fairly Last Contact Once Twice Rarely Occasionally Often Total Under 15 2.9 1.2 1.4 2.2 0.6 8.4 15-19 0.9 0.8 1.2 1.3 0.9 5.2 20 + 0.S 0.9 1.S 1.9 1.4 6.7 Total 4.6 2.9 4.4 5.5 2.9 20.3 SOURCE: Fas et al. (in press). percent of married men have had adult homosexual experiences that, in some period in their lives, were fairly frequent. These estimates diverge from the Kinsey estimate that 4 percent of men are exclusively homosexual throughout their lives. Of course, a question remains as to which estimate is closer to the "true value." We are presently unable to answer this question with confidence. There is no doubt that the sample of persons interviewed in the 1970 Kinsey Institute survey was more "representative" of the American aclult population than the earlier Kinsey samples. What remains un- known is the nature and extent of the survey's interview biases. (We do not know, for example, whether the personal interviews of Kinsey ant! colleagues [1948] achieved more [or less] accurate reporting of the experience of respondents than could be obtained with a written questionnaire, the procedure used in the 1970 survey.) However, the sampling methodology of the 1970 survey should eliminate the kind of sample bias that plaguer! the original Kinsey collection. On the other hand, the level of nonresponse in the 1970 survey reintroduces the possibility of substantial bias in the composition of the sample of men who actually responded to the relevant survey questions. This issue is of particular importance because, as Cochran and coworkers (1953:675) wrote of the Kinsey studies, no sex study of a broad human population can expect to present incidence data for reported behavior that are known to be correct to within a few percentage points. Even with the best available sampling techniques, there will be a certain percentage of the population who refuse to give histories. If the percentage of refusals is 10% or more, then however large the sample, there are no statistical principles which guarantee that the results are

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126 ~ UNDERSTANDING SPREAD OF HIV correct to within 2 or 3 per cent.... [A]ny claim that this is true must be based on the undocumented opinion that the behavior of those who refuse to be interviewed is not very different from that of those who are interviewed. It should be noted, however, that Pay anct colleagues (in press) report a reanalysis of newly available data collected by Michael and coworkers (1988) that-provides some corroboration of the estimates obtained from the 1970 Kinsey Institute survey. Although coding categories cannot be precisely matched, estimates of rates of same- gender sexual contact during the preceding 12 months appear similar to those obtained in the 1988 NORC General Social Survey. The difficulties of gathering reliable ciata on the number of per- sons with same-gender sexual experience are quite obvious. The behavior remains the object of considerable social hostility, and some people, for various reasons including fear of discrimination (and worse), conceal their experiences, even within important so- cial relationships. In a social survey, this segment of the population may have considerable incentive to refuse to respond or to deny its experience. It is also important to remember that these studies were con- clucted during a period in which the earlier reform movements within the "homosexual community" coalesced politically and became the gay liberation movement. In part driven by those who were self- identified as homosexual and in part prompted by other social move- ments of the period, political activism increased within what was to become the community of gay men and lesbians (R. A. L. Hum- phreys, 1972; D'Emilio, 1983~. This political activism was imple- mented at a number of levels: practical electoral politics in those communities with substantial populations of gay men and lesbians; attempts to increase social services in local communi- ties, including services for the young and elderly and improved police-community relations; . coalitions to foster gay rights at the state and national levels; . development of gay caucuses within professional and scientific societies; and an intellectual ferment about the nature of sexual prefer- ence and its relation to the larger social order—including its relation to scientific investigation.

SEXUAL BEHAVIORS ~ 127 The complex research agenda that characterized the period from the early 1970s to the beginning of the AIDS epidemic reflected major changes within the gay and lesbian communities themselves. The de- cision by a large number of people to openly label themselves gay men or lesbians changed the experience of same-gender sexuality. From a relatively narrow "homosexual" community based primarily on sex- ual desire and affectional commitment between lovers and circles of friends, there emerged a community characterized by the building of residential areas, commercial enterprises, health and social ser- vices, political clubs, and intellectual movements. This process has been chronicled in the gay and lesbian press, but historical analy- sis is just beginning (see, e.g., D'Emilio, 1983; Katz, - 1976, 1983~. Such communities did not emerge everywhere: many people partic- ipated primarily as passive members; still others continued to use the community primarily for the sexual access it provided through its increasing number of leisure institutions. Nevertheless, the ex- istence of such communities changed the experience of those with same-gender sexual preferences and their relation to the larger com- munity. Increasingly, gay men and women began to see themselves as a minority similar to other social and ethnic minorities (Weinberg and Williams, 1988~. It is possible to identify a number of research programs begun in the early 1970s that differed substantially from earlier studies. They were often associated with specific reform agendas and openly included gay men and lesbians as full scientific participants. This is one of the most crucial changes in the landscape of research on same- gender sexuality: people who would have been only the subjects of research and barred from participation as researchers because of their "biases" became valued members of research programs. These programs included the following types of endeavors: . . Studies of homophobia and prejudice against gay men and lesbians following the research tradition that asks why majority groups fear and hate minorities (pioneered by studies of anti-Semitism). Such research involves lo- cating persons who seem more likely to express such feelings as a function of their social location or psycho- logical predispositions. Applied studies, particularly within professional organi- zations, that seek to identify sources of discrimination against gay men and lesbians. Within professional soci- eties, this type of study includes discrimination against research on same-gender sexuality or preference.

128 ~ UNDERSTANDING SPREAD OF HIV . Studies of mental health among gay men and lesbians. · Studies of gay mate and lesbian communities, often fo- cusing on political and social issues rather than matters of sexuality or social and psychological adjustment. . Studies of the possible childhood or biological origins of same-gencler sexuality (A. P. Bell et al., 1981), which often provoke fierce political debate, as do discussions of the social construction of gay mate or lesbian identities (Dececco, 19883. Attempts to recover the history of same-gender desire in various historical periods, including the recent past. Ma- jor developments have involved the creation of research archives, oral histories, and the use of previously sup- pressed materials and archives on earlier periods (e.g., Katz, 1976; Dover, 1978; Boswell, 1980~. This is one of the most active current research areas within gay male and lesbian communities. Research on Same-Gencler Male Sex Since the Onset of the AIDS Crisis The first recognized risk group for AIDS in 1981 was men who reported having sex with other men (CDC, 1981a,b,c; Ffie~lman- Kien, 1981; GottTieb et al., 1981; FolIansbee et al., 1982; Ffiedman- Kien et al., 1982~. The clustering of cases among male same-gender sexual contacts (CDC, 1982) established the fact that AIDS was sexually transmitted. To determine the specific aspects of sexual behavior responsible for transmitting and promoting AIDS, more than 15 major studies of gay mate sexual behavior and its relation to AIDS were undertaken in the United States from 1982 to 1984. Research was conducted! primarily in San Ffancisco, Los Angeles, Chicago, Pittsburgh, Baltimore, Washington, D.C., and New York City. Most of these studies employed longitudinal designs and are thus ongoing; however, many interim reports have been published, through which the primary mo(le of transmission of HIV among homosexual men (unprotected anal intercourse) has been established. In adclition, there now exists an extensive and expanding data base on gay mate sexual behavior patterns—a source of information that dicl not exist prior to the AIDS epidemic. The link between sexual behavior and AIDS was elaborated dur- ing the early 1980s. Prior to the discovery of HTV in 1983-1984, two

SEXUAL BEHAVIORS 129 case-control studies on ATDS were conducted. The first study (Mar- mor et al., 1982) focused on men in New York City and compared AIDS patients who had Kaposi's sarcoma with control subjects who were not ill. In addition to inhaled nitrite use and frequency of sex- ually transmitter! disease, a key difference between ATDS patients and controls was the number of different sexual partners reported by each group. Subjects with AIDS were more likely than control subjects to have had 10 or more different partners in a typical month prior to the onset of symptoms. In an expansion of this stucly (ad- ditional cases and control subjects from other U.S. cities were added to the data set), Jade and coworkers (1983) replicated this finding. In their research, subjects with ATDS reported an average of 61 dif- ferent sexual partners over the year prior to symptom onset, while control subjects reported an average of 25. These investigators also found that, compared with control subjects, significantly more sub- jects with AIDS met their sexual contacts at gay bath houses. In addition, subjects with AIDS had higher mean scores than control subjects on a measure of fecal exposure during sex. Using helper T-cell counts as the disease marker of interest, Goedert and coworkers (1985) showed that gay men in Washington, D.C., who had sexual contact with men from New York City were more likely to have Tow helper T-cell counts than were Washington gay men who did not have contact with men from New York City. The Goedert team also found that the frequency of receptive anal in- tercourse among these men was associated with a decrease in helper T cells. This association between receptive anal intercourse and re- duced helper T ceils was also demonstrated by Detels and colleagues (1983) in Los Angeles. Thus, before the viral cause of AIDS was known or detectable, behavioral research had shown that being sick with AIDS or showing laboratory signs of immune deficiency was associates! with (1) a large number of different sexual partners; (2) receptive anal intercourse or other rectal trauma; (3) the use of bath houses for sexual contact; (4) frequent infection with sexually transmitted diseases, particularly gonorrhea, syphilis, and enteric parasites; (5) sexual contact with gay mate residents of New York City; and (6) the use of inhaled nitrites. There hacT been no consensus about a disease model of AIDS prior to 1984, however, and consequently, there was much controversy over whether AIDS eras an infectious, transmissible disease or a disease brought on by the immunologic consequences of unhealthy and ex- cessive involvement with sex and drugs (Martin and Vance, 1984~. This debate, combined with the emphasis on the extremely large

130 ~ UNDERSTANDING SPREAD OF HIV numbers of sexual partners and evidence of drug use among urban homosexual men, hac! the unfortunate effect of diverting attention away from specific behaviors. A stereotype of the gay person with AIDS hack emerged from the scientific work, and this stereotype, which was picked up by the popular media, made it appear that the disease afflicted only the most "reckless" gay men.23 The stereotyping of AIDS also resulted in a similar distancing phenomenon in the larger, heterosexual population. AIDS was con- siderecI to be an affliction that was limited to gay men. Indeed, prior to the adoption of "acquired immune deficiency syndrome," the dis- ease was referred to as the gay-related immune deficiency or GRID, the gay plague, and gay cancer. The result of such labeling was that AIDS was presented to the public as a disease whose threat was re- stricted to gay-identified men. Although the early research on AIDS had correctly identified key transmission factors for the disease, the focus on the risk group rather than on specific risky behaviors may have interfered with accurate assessments of personal risk, based on their individual behavior, among gay ant! nongay persons. The discovery of HIV in 1983-1984 coincided with the estab- lishment of the Multicenter AIDS Cohort Studies (MACS) by the National Institute on Allergy and Infectious Diseases (see the clescrip- tions in Kasiow and colleagues [1987~. Five centers were awarded contracts: Los Angeles, Baltimore, Pittsburgh, Chicago, and San Fiancisco/Berkeley. (To conduct their research in an unconstrained fashion, the San Ffancisco/Berkeley group became independent of the other four centers early in the planning stages of the study.) The purpose of these cooperative studies was to recruit ant! follow an initially AIDS-free cohort of approximately 5,000 gay men over a three-year period to determine the natural history of AIDS and HIV infection. A key strength of the MACS design lay in the large number of subjects to be recruited and the administration of a common core of assessment instruments regarding sexual behavior and drug use. The limitations of the design for studying future disease transmis- sion lay primarily in the ways in which subjects were recruited. The MACS recruited volunteers who were most often self-identified gay men and members of the local gay communities. They tended to be disproportionately white, well educated, and middle class, and those few who were less educated or less affluent, or who were members of minority groups, were usually attached in some way to members of the majority. This skewing is exactly what has characterized nearly 23For an example of this view in the popular media, see "Gay America in Transition," Newsweek, August 8, 1983:30.

SEXUAL BEHAVIORS ~ 131 all studies of homosexual men (and lesbians) as far back as the Kinsey studies (Davies, 1986; Schreiner, 1986~. Mends in Same-Gencler Sexual Behavior Anal Intercourse Published reports based on MACS data established the role of re- ceptive anal intercourse in the transmission of HIV (Chmie] et al., 1987; Kingsley et al., 1987; Polk et al., 1987; Winkelstein et al., 1987a,c). This key finding has been replicated and reported by other research groups involved in major epidemiological work with gay men in Boston (Mayer et al., 1986), New York City (Goedert et al., 1984; Martin, 1986b,c; Stevens et al., 1986), and San Francisco (D arrow et al., 1987b; Moss et al., 1987~. Receptive anal intercourse without a condom is the only sexual behavior for which a consistent level of risk can be demonstrated in the epidemiological analyses reported in these studies. In multivariate analyses of HIV risk, unprotected! receptive anal intercourse statistically overwhelms all other sexual acts. It is important to note, however, that the lack of detectable statistical risk for sexual acts other than receptive anal intercourse cannot be taken as evidence that no other type of sexual contact carries the risk of transmitting HIV infection. As noted by all of the investigators cites! above, sexual behaviors are highly intercorrelated; thus, the unique risk associated with only one particular act can never be accurately evaluated. Two separate case reports24 indicate that HIV infection occurred in the absence of anal intercourse activity for at least three years. In both of these cases, frequent receptive oral-genital sex was reported. In a review of the evidence on the risk of HIV transmission through homosexual contact among men, a recent lOM/NAS report concluded that "cohort and case-control studies of homosexual men . . . show that the risk of HIV infection is greatest for persons who engage in receptive anal intercourse. The risk of infection is less for partners who engage in insertive anal intercourse, and the risk appears even Tower for oral receptive intercourse" (IOM/NAS, 1988:43~. The risk of HIV infection among highly sexually active gay men decreases significantly with the cessation of receptive anal intercourse 24Mayer and DeGruttola (1987~; J. L. Martin, Columbia University School of Public Health, personal communication based on unpublished data (1988~.

132 ~ UNDERSTANDING SPREAD OF HIV (Winkelstein et al., 1987a; Martin et al., in press). The large-scale re- duction in the frequency of this particular sexual practice is believed to account for the near elimination of new cases of HIV infection (as of 1987) among participants in gay male cohort studies. Inciclence rates of less than 0.5 percent have been observed in San Ffancisco (Winkelstein et al., 1987a), as well as in New York City.25 In addition to the longitudinal MACS studies, a number of other investigators have been following cohorts of gay men to compile detailed behavioral data over time. In a recent review by Becker and Joseph (1988), it was shown that- ciata from San Francisco (McKusick et al., 1985; Winkelstein et al., 1987a,c), New York City (Martin, 1986a, 1987a), and Chicago (Emmons et al., 1986; Joseph et al., 1987) converged on the finding that, beginning in 1986, between 50 and 90 percent of the gay men in these samples had abstained from insertive or receptive anal intercourse. Similar changes have been described among gay men in Boston (McCusker et al., l98Sb). This conclusion cannot be generaTizecl to less populated geo- graphic regions of the Unit en States, however. In a survey of gay men in urban areas of New Mexico (C. C. Jones et al., 1987), it was found that 70 percent of the sample had engaged in receptive anal intercourse in the year prior to the interview (1984-1985), and most clid so without condom protection at any time. Similarly, Beeker and Zielinski (1988) reported that gay men in upstate New York engaged in unprotected receptive anal intercourse during 1986 at a rate twice that of gay men in New York City. Such geographic variation in unprotected! anal intercourse rates underscores three needled actions: (1) continuation of existing descriptive epiclemiological studies of gay mate sexual behavior, (2) initiation of new epidemiological studies of gay mate sexual behavior in less populated geographic regions of the country, and (3) intensified prevention efforts aimed at reducing rates of unprotected anal intercourse among gay men living outside the major U.S. metropolitan areas. Condom Use Safer sex guidelines recommence the use of condoms for both oral sex and anal intercourse, but condom use rarely accompanies oral sex among gay men (Martin, 1987a). Although the incidence of condom use with oral sex has certainly increased from 1981 to 1986, no more than 5 percent of respondents in a New York City sample reported the 25J. L. Martin, Columbia University School of Public Health, personal communication based on unpublished data (1988~; J. L. Martin et al. (in press).

SEXUAL BEHAVIORS ~ 133 consistent use of concloms for oral sex (Martin, 1987a). Estimating the rates of conclom use during anal intercourse has proven more difficult than estimating intercourse activity per se. Condom use tends to be highly variable over time as well as across situations. For example, both Des JarIais (19883 and Martin and colleagues (in press) report that individuals are less likely to use a condom when they engage in sex with a primary partner than when they engage in sex with a less well-known partner. Even within a particular partner dyed, the relative frequency of condom use varies. There are few data on the rate of con(lom failure, breakage, or slipping in natural (versus laboratory) settings with regard to homosexual anal intercourse.26 Obtaining convergent data across studies is not possible because the time frame (i.e., a week, month, or year) varies from study to study and the particular point in time (i.e., the date) also varies. McKusick and colleagues (1985) found that ~ percent of San Fran- cisco respondents used a condom during anal intercourse (although the frequency was unspecified) during the latter half of 1983. In another study of San Fiancisco gay men conducted by telephone in 1985 (Research and Decisions Corp., 1985), 7 percent of the sample reported engaging in unprotected anal intercourse outside of a "pri- mary relationship." Some of the clearest data on condom use among gay men come from the study by Martin and coworkers (in press). Using episodes of receptive anal intercourse as the unit of analysis, these investigators found an increase in protected episodes from fewer than 1 percent in 1981 to 19 percent in 1985, 60 percent in 1986, and 71 percent in 1987. Shifting the unit of analysis to indiviclual respondents, these investigators found increases (from 2 percent in 1981 to 62 percent in 1987) in the percentage of men who always used a condom cluring anal intercourse. Other Sexual Activities Gay men appear to be highly sensitive to the publicized risk cliffer- entials between oral-genital sex (perceived as low-risk activity) and anal intercourse (perceived as higher in risk). IndeecI, the perception of high risk associated with all sexual acts involving anal contact or 26There is reason to suspect that findings from studies of condom breakage during heterosexual vaginal intercourse (e.g., Free et al., 1980, 1986) may not generalize to anal intercourse. Wigersma and Oud (1987) have reported data from a study of 17 gay couples in the Netherlands who reported their experiences with five brands of condoms (used with different quantities of lubricant). Rates of condom rupture (per "test" session) ranged from O percent for the "stiffest" condom to 13 percent for a condom rated among the least "stiff." Condoms were reported to "slip off" in 0-10 percent of test sessions.

134 ~ UNDERSTANDING SPREAD OF HIV the ingestion of semen is clearly reflected in the behavioral trends over time that have been observed in the cohorts studied in Chicago (Joseph et al., 1987), New York City (Martin, 1986a, 1987a; Martin et al., in press), and San Francisco (McKusick et al., 1985~. These studies indicate that, in contrast to insertive ant! receptive anal inter- course, receptive and insertive oral-genital sex without swallowing semen or ejaculating in the partner's mouth are still common sexual practices among gay men. For example, the most recent estimates from New York City (Martin et al., in press) suggest that, in 1986, although 80 percent of gay men either abstained entirely from or always used a condom cluring anal intercourse, approximately 85 percent of gay men engaged; in oral-genital sex (without a condom) at least once during the year. It is important to note that, in the large natural history studies, more esoteric sexual practices (e.g., oral-anal activity tanilingusi, listing, and behavior involving the ingestion of urine and fecal ma- terial) have shown no consistent association with HTV infection or AIDS. These practices were the focus of much early speculation about the reason homosexual men were the primary targets for AIDS; yet the descriptive epidemiological studies that have since become avail- able indicate that these practices were relatively rare compared with oral-genital sex and anal intercourse. In addition, current estimates indicate that fewer than 20 percent of gay men engage in oral-anal sexual contact (Joseph et al., 1987; Martin et al., in press), and fewer than 1 percent engage in listing activities or the ingestion of urine or fecal material.27 These data suggest that educational messages must underscore the facts that HIV is transmitted through widely prac- ticed sexual activities and that transmission is not limited to those who engage in what might seem to be unusual sexual practices. Celibacy, Monogamy, and Multiple Partners Published studies of gay mate sexual behavior and its relationship to AIDS and HIV infection have clemonstrated significant declines in the average number of sexual partners reported by gay men. Representative findings include the following: . in San Ffancisco, from 1984 to 1986, a 60 percent decline was observed in the number of men reporting 10 or more sexual partners in a six-month period (Winkelstein et al., 1987a); 27J. L. Martin, Columbia University School of Public Health, personal communication based on unpublished data (1988~.

SEXUAL BEHAVIORS ~ 135 . in Chicago, from 1985 to 1986, the average number of sexual partners declined by 2 percent per month (Joseph et al., 1987~; anc3 . in New York City, from 1981 to 1985, the median num- ber of sexual partners declined by 72 percent (Martin, 1987a). These dramatic reductions in numbers of partners reflect, in part, a substantial decline in the use of extradomestic locations for sex in particular, gay bath houses, sex clubs, and the back rooms of bars. McKusick and colleagues (1985) reported a 60 percent Recline in 1983-1984 among their San Ffancisco cohort in the average number of visits to sex clubs or bath houses. In New York City, Martin (1987a) reported a decline from 50 percent to 10 percent in the number of men using a gay bath house for sex between 1981 and 1985. Although the location in which sex occurs is unlikely to be directly related to the transmission of HIV or other diseases, it is important to note that locations such as gay bath houses and sex clubs functioned for gay men in the same way "shooting galleries" (see Chapter 3) have functioned for drug injectors in establishing the AIDS epidemic and the spread of HIV infection. Such locations provide settings that promote transmission-related behavior at a rate far beyond that possible outside these settings. This conclusion is supported by New York slate (Martin, 1987a) indicating that in 1981 the meclian number of (cumulative) sexual partners reported in sexual encounters in extra(lomestic settings was 36; in contrast, the median number of partners reported in sexual encounters in domestic settings was 5. Although the average number of sexual partners reported by gay men has declined rapidly since the onset of AIDS, rates of monogamy (i.e., confining sexual relationships to a single partner) and celibacy have increased slowly. A comparison of these rates across studies is difficult because the various investigators did not use a standard time frame. For example, McKusick and colleagues (1985) reported that 41 percent of their San Ffancisco sample were monogamous for one month in 1983. Joseph and coworkers (1987) reporter! that, in their Chicago cohort, the rate of monogamy rose from 18 percent to 25 percent over a six-month period in 1984-1985. Martin and colleagues (Martin, 1986a; Martin et al., in press) reported increasing rates of monogamy in New York City over contiguous yearly periods from 1985 through 1987. However, these rates were strongly influenced by c,

136 ~ UNDERSTANDING SPREAD OF HIV whether respondents were involved in a primary relationship28 with another man. Among those so involved, monogamy increased from 18 percent in 1985 to 25 percent as of 1987; among those gay men not involved in a primary relationship, the rate of monogamy rose from 7 percent in 1985 to 11 percent in 1987. Yet despite the difficulty in making cross-study comparisons of rates of monogamy, the data clearly converge on the fact that the majority of gay men, whether partnered! or single, has not acloptecI monogamy in the wake of the AIDS epidemic. Neither has there been a dramatic increase in the rate of celibacy among gay men (Martin, 1987a). Taken together, the available ciata indicate that the primary shifts that have occurred among gay men in response to AIDS/HIV have been in the realm of specific sexual practices, rather than in the adoption of monogamy or the elimination of sexual contact altogether. Eight years into the AIDS epidemic, oral sex without the exchange of semen, abstinence from all types of anal sex, and the use of condoms by the minority who continue to engage in anal intercourse appear to characterize mate homosexual sexual behavior in major U.S. metropolitan areas. FEMALE PROSTITUTION There is a general belief that female prostitution might play an im- portant role in the spread of HIV infection in Western nations.29 Indeed, some policy makers in the United States ant! in other coun- tries have called for or instituted various measures to "control" the potential spread of the disease by controlling the behavior of pros- titutes. Such measures range from the punitive (mandatory testing and imprisonment) to the more supportive (the provision of educa- tion and condoms). There appears to be some interest in protecting prostitutes from infection, but the more prominent concern of policy makers seems to be the role of prostitutes in spreading the disease into those groups that are currently at Tow risk of infection. 28Martin (1987a:578) operationalized the definition of having a primary relationship with a lover as follows: "A respondent qualified as having a lover if: 1) he said he had a lover; 2) his lover viewed him as his lover (reciprocity); 3) friends viewed the two as a couple (public recognition); and 4) the relationship was extant for six months or more (duration)." 29In our review, we focus on female prostitution, not because of its greater epidemio- logical importance but rather because of the extreme paucity of scientific evidence on patterns of male prostitution. As noted subsequently, the committee recommends that research to fill this gap be given high priority.

SEXUAL BEHAVIORS ~ 137 Prostitutes' increased risk of becoming infected and transmitting the virus is thought to result from the sexual activities involved in their work and the association between IV drug use ant! prostitution in some groups. The relevant sexual practices include having a large number of sexual partners with limited ability to discriminate among them; specific sexual practices (i.e., anal sex) that may increase the risk of HIV transmission; and the inability, for whatever reason, to use safer sex techniques. - In addition, prostitutes may have a history of other STDs, a factor that may increase the likelihood of transmission. Lending support to these views is the evidence from central African societies showing that prostitution has played an important role in the transmission of the disease among heterosexuals there (Kreiss et al., 1986; Plot et al., 1987a; see also the discussion by Alexander t1987a] on the relevance of the African data to the U.S. situation). Prostitutes occupy a marginalized social niche that offers the possibility of personal and economic exploitation by other individ- uals and groups in the society (e.g., the police, pimps, criminals, customers) (Gagnon, 1977; HeyT, 1977~. The experiences of exploita- tion and oppression these women undergo often produce disorclerly lives over which they feel they have little control blames, 1980~. Their ability to manage their sexual interactions or to engage in safer sex practices may be limited. Customer demands for specialized services and pressure to provide them at higher prices may override any desire to engage in safer sex practices. In some locales, there is a substantial amount of {V drug use among prostitutes or the frequent association of prostitutes with TV drug users (Goldstein, 1979~. The actual proportions of prostitutes who are {V drug users or who associate sexually with TV drug users are uncertain, but there is evidence that such proportions are sub- stantial among minority populations and in certain regions of the United States. For example, a 1987 survey of street prostitutes in the New York City area indicated that approximately one half had injected cirugs at least once and one third hacT injected cirugs at some time during the previous two years (Des Jarlais et al., 1987~. Although these factors suggest that female prostitution could play a role in the AIDS epidemic, there is very little actual evidence about the role of prostitution in the transmission of HIV (Alexander, 1987a). IndeecI, there is very little evidence about most of the im- portant dimensions of prostitution that are relevant either to disease spread or to the behavioral changes that could limit such spread.

138 ~ UNDERSTANDING SPREAD OF HIV Social Context of Prostitution Prostitution attracts a great deal of public attention, usually either as a social problem or a moral clilemma, but the research that has been conclucted on its internal organization as an occupation or on its actual service relation to the larger social community is relatively meager. Much of the information on prostitution that has been col- lected in the United States has been motivated by concerns for social control or social change, sometimes provoked by national emergencies (e.g., the health of servicemen cluring World Wars I and II; see Brandt [1987~) ant! sometimes by local moral crusades. Such information is often partisan, unsystematic, anecdotal, and alarmist devoted to "cloing something" about prostitution and the prostitute. All prostitution shares the common characteristic of (and, in- deed, is defined by) exchanging sexual activity for payment; as a re- sult, it has a superficial appearance of similarity in all social contexts (as reflected in the modern phrase, "the worlcl's oldest professional. Yet the actual social organization of prostitution and its meaning in any specific society or culture can be quite different (Gagnon, 1968; James, 1977~. In the United States, for example, both the social orga- nization of prostitution as an activity and its relation to the "sexual economy" of the larger society have changed over the past 80 years. In the early years of the century, bor(lellos and street prostitution (which were the most common ways in which prostitution appeared in large cities) were suppressed as part of the sustained efforts of "health and purity" crusaders (Bran(lt, 1987; Hobson, 1987~. By the end of World War II, even the most recalcitrant of the vice zones in American cities were disappearing. Prostitution was also affected, from the late nineteenth century on, by a decline in steady customers as a result of a reduction in the number of permanently single men in the population and the steady increase in the sexual accessibility of "good" women as part of a changing courtship system (see the discussion earlier in this chapter). The Kinsey data suggest that reg- ular and frequent contact with prostitutes declined between the two florid wars, although the incidence of such experience remained high (Kinsey et al., 1948~. Thus, female prostitution may play a different role in the lives of men today than it clid in the past. One of the most important forces shaping the organization of female prostitution is the twofold (formal and informal) regulatory apparatus that is (revoted to controlling it. (For a careful description and review of the differences among the United States, the Nether-

SEXUAL BEHAVIORS ~ 139 lancis, and Sweden, see Hobson [19874.) Prostitution is usually man- agecl formally by the state, either through the criminal justice system or through a combination of the criminal justice system, disease con- trol agencies, and welfare activities (Decker, 1979~. In the United States, prostitution is a criminal offense in all states except Nevada, which regulates brothels (Alexander, 1987b:195~. In practice, this criminalization has resulted in situations in which the local police, prosecutors, and courts have attempted some or all of the following courses of action: . to suppress prostitution entirely by systematic and ag- gressive enforcement; . to suppress prostitution in certain areas of the commu- nity and allow it in others, creating informal zones of tolerance or de facto legalization of non-street prostitu- tion (Alexander, 1987b); . to engage intermittently in widely publicized crusades against prostitutes at the instigation of citizens' or offi- cial groups; or . to arrest at regular intervals a certain number of prosti- tutes who work in the most exposed locations. Short of attempts to suppress prostitution entirely, all of these techniques may involve either some corruption of the police or an accommodation between the police and the criminaTized populations, which produces irregular enforcement. The way in which prostitution is organized in most communities is usually a response to these social control policies and practices. Because of the legal ant! moral status of prostitution, it is clifficult to supply answers to a wide variety of questions that are relevant to the role prostitution might play in the epidemic. For example, there is no good estimate of the number of women who work as prostitutes. The usual sources of data are either arrest and imprisonment records, which are known to select primarily those populations most vuIner- able to the criminal justice system (the poor, minorities, drug users, the inexperienced, those working on the street), or estimates by vari- ous "knowledgeable" observers. Such estimates vary quite widely. In fact, no one knows how many women work full-time, part-time, or only intermittently as prostitutes. Nor does anyone know how many women have ever worked as prostitutes ant! what their career paths have been—how old they were when they started, how steadily they worked, whether they have left and then returned to the occupation, and the periods involved in these exits and reentries.

140 ~ UNDERSTANDING SPREAD OF HIV There is some information suggesting that the background char- acteristics, patterns of recruitment, work careers, and departures from the occupation of prostitute vary considerably across cultures and societies; this knowledge is based on ethnographic studies, bio- graphical statements, or expert testimony rather than on fully sys- tematic research ~ The Streetwalker, 1959; Young, 1964; Bryan, 1966; James, 1976; Barrows and Novak, 1986; L. Bell, 1987; Delacoste and Alexander, 1987; SchecIl-in, 1987~. It is also known that women do not move randomly into prostitution and most of them do not remain in it for a lifetime. The sectors from which female prostitutes are re- cruited vary substantially for different groups within large societies. How a woman manages a life in prostitution will often depend on (1) the resources or skills she brings to the work, (2) the quality of available opportunities to learn the requisite social and sexual skills to maintain her own sense of identity and her relations with the "important people" in a new social world (Bryan, 1965; HeyT, 1977; Silbert ant! Pines, 1982~; and (3) the structural constraints on her ability to work in the most profitable ways (e.g., black prostitutes have difficulty working in gambling casinos). Movement out of pros- titution into a more conventional life will also depend on such skills and resources, as well as on a certain degree of luck regarding the woman's original placement in the prostitution system (Delacoste ant! Alexander, 1987~. For some women in some societies, prostitu- tion may be a vehicle for upward social mobility or an alternative to occupations that present an even greater danger to their survival. The site of a prostitute's work appears to have major effects on her life (Cohen, 1980; Carmen and Moody, 1985~. The availability and dangerousness of sites usually depend on the legal status of prostitution in a particular locale and on informal agreements with the police. Women find customers on the street, in bars, and in official or unofficial zones; they work out of cars, in brothels, and over the telephone. The sexual act or acts are carried out in private or semiprivate places such as hotels, vehicles, bedrooms of bordellos, on the streets, and in other semiprivate public spaces. The more public the access to customers and the more public the sexual activity, the greater the risk of involvement with the police and the greater the risk of assault, rape, or robbery by passersby or customers. Those women who are most vulnerable to "trouble" have in fact provided the most information about the psychological and social backgrounds of prostitutes. The type of clientele a prostitute serves is critical to her economic and personal life. Knowledge is very sketchy about the number of

SEXUAL BEHAVIORS ~ 141 customers served by individual prostitutes working at different sites during specific periods. The social characteristics of these customers are likely to depend! on the place of work and its relation to the community. Some studies have asked women to estimate the number of their recent partners, but there is apt to be considerable error in these counts, as well as in their reporting of the social characteristics of clients (in part, these errors rest on both inadequate knowledge and inadequate recall). Although prostitutes are often recruited from Tower socioeconomic strata and minority populations, clients come from all social strata. If women work in rural or Tower socioeconomic areas, their clients are often from the same social levels. In many urban areas, however, prostitute populations are only partially strat- ified by the socioeconomic status of their clientele. Women who work the streets may serve somewhat poorer clients while women who work by phone may have a more affluent clientele, but this is not always true. In some cities, brothels are socioeconomically stratified as a function of cost. There appears to be some mobility of the more attractive and more socially skilled prostitutes to client populations of higher socioeconomic status, but the extent of this mobility has not been documented. Depending on their work sites and on other factors, prostitutes will have varying levels of control over the number of clients they have in a day or week. Women who work in zones or in bordellos that serve working-cIass men (especially men who are without other women) may have many men each clay. Those who work on the telephone will have far fewer. There is evidence that prostitutes who serve working-cIass clients, at least in Western societies, are more likely to be asked for "straight sex," while midlife- and upper-cIass clients will often ask for more experimental sexual activities (Gagnon, 1977~. There is also some evidence that many women attempt to have oral sex rather than intercourse with clients because of the lower level of effort involved and the potentially higher payment. However, women may experience pressure (from "pushers," e.g., pimps and madams, whose income is dependent on their efforts) to increase the number of clients they serve or to accede to all of the sexual desires of clients (including not using condoms). The incomes of prostitutes vary enormously, as do their ex- penses. Call girls may charge more per customer, but they must keep up an expensive front. Many prostitutes must pay off officials, even in countries in which prostitution is legally regulated. Many women have men to support, even when they do not have pimps. Still others have children for whom they are responsible. Like all

142 ~ UNDERSTANDING SPREAD OF HIV marginal occupations, prostitution must confront the dangers of un- employment, uncleremployment, illness, or injuries from violence at work (without health insurance or compensation), as well as the risks of arrest and imprisonment and hence the costs of bait bonds, lawyers' fees, loss of employment time, and so forth. This lack of control of important dimensions of life creates psychological bur- dens for the individual prostitute that cannot be attributed to prior "psychopathology" (Jackman et al., 1963~. Prostitution and AIDS The role of prostitution in the transmission of sexually transmitted diseases (STDs) other than AIDS has received more attention as a pretext for social control than as a subject of research (Brandt, 1987; Hobson, 1987:Chapter 6~. A useful review of research on the role of prostitution in the transmission of STDs prior to the AIDS era can be found in D arrow (1983~. D arrow points out that the surge of STDs in the 1960s was probably as much a function of failures of the health care system (e.g., in ignoring the behavioral patterns of disease transmitters) as it was a consequence of the increased use of nonbarrier contraceptives, increased numbers of sexual partners, and other changes in sexual practices. The general belief that prostitutes do not play an important role in the transmission of STDs may be incorrect, particularly for such "new" diseases as herpes and chIamydia (D arrow, 1983~. As a result of the AIDS epidemic, health agencies have shown increased interest in female prostitution, ant! CDC has thus begun coordinated studies in collaboration with research groups in Las Ve- gas, Atianta, Colorado Springs, I,os Angeles, San Ffancisco, Miami, southern New Jersey, and northern New Jersey (Darrow, 1988~. The rates of HIV infection found in these convenience samples as of Jan- uary 1988 are shown in Table 2-~. Perhaps the most important finding of this study is that HIV infection in the prostitutes studied thus far is found predominantly among those with histories of IV drug use. In the total collection of cases (1,456), 727 women showed evidence of {V drug use. Of these women, 150 (20.6 percent) were HIV seropositive. Data reported at the Fourth International Con- ference on AIDS from this same study suggested that, of one group of women who showed no evidence of IV drug use, only 38 of 729 (about 5 percent) were infected with HIV, and the majority of those infected came from one research site (24 of the 38 were from Miami)

143 C) o Cal Ct a) - Ct o ._ ._ cq o ._ ._ be Ct be o o '\~ o o C) C. o sly Cat _ sly Cal C. Cal .= C) o Cat U. _ _ Cal o Pa V be Ct C) o - 40 o C) ._ ~ a O '_ 40 O a I ~ . U: So ~ Cal ~ ~ . Cal ~ ~ ~ ~ ~ ~ § ~ § ~ ~ ~ ~ ~ ~ o.= ~ ~ ~ ~ a ~ ~ ~ ~ ~ · - 0 ~ ~ ~ ~ ~ ~ ~ ~ 0 ~ ~ 0 ~ 0 ~ _ ~ ~ ~ ~ ~ ~ ~ ~ ~ C~ ~ 00 00 CD C~ C~ C53 0 — 00 C~ CD _ ~ CO C~ ~ ~ _ _ _~ _ _~ _~ ~ - _' 00 0 0 ~ ~ ~ 00 ~ . . . . . . . . O O C~ ~ ~ ~ _ 00 C~ _ ~ ~ _ ~ C~ . . . . O O O ~ O 00 0 00 ~ - ~ ~ ~ ~ C~ ~ ~ C~ . . . . . . . . O _ C~ C~ ~ CO C~ ~ O ~ ~V V: ~ ~ ~ _ C o 3 3 b.0 o V' ~ _ ~ ~ Ct ~ ~ ~ ~ ~ ~ ° ~ ~ ° Z - ° ~ L~ oo 4- ~o c~ ~ a, s~ ~ C~ o ,= o0 U 0 ~ · ~ ~ ~ . ·o ~o . ~ 0 C~ ~o ~ ~ ~ ~ Ct ~ C;: =° ~ ~ ~^ ~ ~ C: ~ 5 .= ~ C') :'s "S .> O 3 ~ . _ Ct ~ ° ~ CtS C) ~ C c: p; =5 ~ ~a~ =^ O .= ~ ~ ~ ~ C~ ~ ~ I ~ C) ._ · r 2 ~4 ~J .= ~ O O ~ a_~ >` .- ,,Q cO~ O >. ~ ~ O ~ C) ~ ~ _ ,= ~ ~ _ ~ O ~ O ·C~ _ . ~ ~o E ~ o ~ ~ ~ o ~ ~ _\ ~ 1 s~ Ct Ct ._ o

144 ~ UNDERSTANDING SPREAD OF HIV (Darrow et al., 1988~.3° At the same time, there are considerable dif- ferences among research sites in the number of drug-using prostitutes who are seropositive for HIV, suggesting that drug-use practices (in particular, needle-sharing) may vary substantially from city to city. The connection between prostitution and {V drug use is not a simple one (Goldstein, 1979~. There is substantial ethnographic and statistical evidence that {V drug use by prostitutes is concentrated among minorities or among women who work on the streets (Schedlin, 19873. In addition, changes in patterns of cirug use among prostitutes parallel those of the larger drug-using community. Thus, increases in the use of injected cocaine and crack smoking as substitutes for heroin appear to be occurring among IV cirug-using prostitutes in those cities in which similar changes are observed among other drug users. There is some anecclotal evidence that women who are recruited into prostitution through a drug habit or women who acquire a drug habit after becoming prostitutes may have somewhat different life careers than those who do not use drugs. The use of cirugs puts women at far greater risk of arrest (there is both the burden of the work and the habit); it may interfere in adopting prudent patterns of work (including safer sex); and it increases interactions with crim- inal populations to secure drugs. In some communities, there are different "strolls" (street areas of work) for those who are drug users and those who are not, with the latter viewing themselves as profes- sional sex workers, unlike those who are driven to the occupation by their need for cTrugs.31 In the most extreme cases of cirug-motivated prostitution, there have been recent anecdotal reports of women be- coming semipermanent residents of crack houses and exchanging sex for crack. The use of condoms by prostitutes has received some attention from researchers. The prevalence of protected intercourse (i.e., the use of condoms) by women in the sex industry appears to vary with the context of the sexual encounter. J. B. Cohen (1987) found that 38 percent of the prostitutes interviewed in this study reported that they "always" used condoms with clients; only 10 percent reported that they "never" used them in professional relationships. However, these women did not view personal relationships as posing HIV-associated risks, and only 14 percent reported using condoms with husbands or 30A more detailed description of the Atlanta study can be found in Leonard and col- leagues (1988~. 31C. B. Wofsy, Departments of Medicine and Microbiology, University of California at San Francisco, personal communication (1988 ).

SEXUAL BEHAVIORS ~ 145 boyfriends. Other studies (e.g., D arrow, 1987b) have confirmed the finding that safer sex is practiced by female prostitutes more often in a professional context than in a personal one. CDC is currently supporting studies of female prostitutes as part of its continuing concern with the role of prostitution in HTV transmission. One study focuses on the sexual and social networks of prostitutes in Colorado Springs; the other, in San Francisco, is a continuation of an outreach, treatment, and social mobilization program (Project Aware) directed at women sex workers. These studies hold promise for understanding the role of prostitution in HIV transmission and as part of the ongoing sexual life of Ameri- can society. In addition, the National Institute on Drug Abuse has fundecl a three-city (Los Angeles, Boston, and Phoenix) outreach and education program that will recruit some 1,500 women who are prostitutes or partners of male IV drug users. This project is aimed primarily at AIDS health intervention and education, but it should also yield some data about prostitution as well. The AIDS epidemic has heightened public and official concerns about the role of prostitution in disease transmission. These con- cerns tent! to overwhelm the important policy debate, particularly within the feminist movement and between feminists and sex work- ers, about the stance that women in general, and sex workers and feminists in particular, should take on the issue of prostitution. A range of positions has been debated, from "suppression and res- cue" to decriminalization (Snitow et al., 1983; G. Rubin, 1984; L. Bell, 1987; Delacoste and Alexander, 1987~. Prostitutes themselves have become increasingly active participants in this debate, and in some locales, they have organized in trade union fashion to protect themselves from exploitation ant! acivance their causes. Research on prostitution and attempts to engage prostitutes in helping to control the AIDS epidemic (as well as other STDs) will have to deal with this debate and with attempts at self-empowerment in organized prosti- tute groups as one of the important conditions of future research and education. The Customers of Prostitutes If data on female prostitution are limited, there is even less available information on their customers (particularly data that have been provicled by the customers themselves). It is reasonable to assume that the risk of HIV infection to the male partners of prostitutes will depend on the frequency with which such men have paid contacts,

146 ~ UNDERSTANDING SPREAD OF HIV the number of different women with whom contact occurs, the sexual techniques that are paid for, and the men's prior history of other STDs. In the Kinsey studies, among white, college-eclucated men, about 30 percent reporter! sexual contact with a prostitute at least once in their lifetime; only 4 percent reported extensive experience. Among men with less than a college education, the proportion reporting some experience was similar (34 percent), but nearly 12 percent reported extensive experience. This difference by education is reflected in the number of prostitute partners reported in a lifetime: among college-educated men, 21 percent reported 10 or more prostitute partners, and 3 percent reported 51 or more partners. The number of prostitute partners reported by men with less than college educations is much higher: 41 percent reported 10 or more partners, and 14 percent reported 51 or more partners. What may be even more striking is that, of the 918 white college men who were asked if they preferred sex with a prostitute or nonprostitute, 7 percent said they were indifferent, 4 percent said they usually preferred a prostitute, and 6 percent said they always preferred a prostitute (Gebhard and Johnson, 1979:425~. However, as noted earlier, these ciata should be treated with great care, given the problematic procedures used for case collection and the fact that they refer to a much earlier period (40 to 60 years ago). Two recent studies provide some useful data on the clients of female prostitutes, although neither study could offer conclusive finclings on the characteristics of these men. Both studies of men who reported contact with prostitutes (with no other HIV-associated behavior) found that approximately 1.5 percent of the men were in- fected with HIV (Chaisson et al., 1988; Wallace et al., 1988~. In the Wallace research, demographic and behavioral data were collected on 340 men in the New York City area who reported contact with prostitutes. The men had a mean age of 33 and an average of 15 years of education; they had a lifetime average of 94 sexual exposures to prostitutes, with a median of 23 exposures. The most common sexual practice was oral sex. Slightly fewer than one half (45 per- cent) of the men studied reported that they never used condoms with prostitutes. The few other studies of the clients of prostitutes suffer from the same kind of sampling difficulties seen in the Kinsey study. Some discuss motivations for using the services of prostitutes (Kinsey et al., 1948; Gibbens and Silberman, 1960; Winick, 1962; G. Pomeroy, 1965; see Gagnon t1977] for a summary). Recent research suggests

SEXUAL BEHAVIORS ~ 147 that power may be important in motivating men to seek sex with prostitutes (Schec3lin, 1987; for evidence offered by prostitutes, see Delacoste and Alexander t19874) because the interaction allows the man to assume that he can do "anything." It would be difficult, although not impossible, to collect adequate data among men who use the services of prostitutes. Such studies would require househoic3 samples in which men are asked about pros- titute use; specialized samples of men who are regularly associated with prostitutes but who might not be included in a household sam- ple; studies of men who are particularly likely to use the services of prostitutes (e.g., men in the military and in other all-maTe oc- cupational groups); and men from cultures in which contacts with prostitutes are considered part of the culturally supported repertoire of sexual life. METHODOLOGICAL CONSIDERATIONS IN SURVEYS OF SEXUAL BEHAVIOR Although there are considerable gaps in knowledge about the sexual behavior of the American population, important advances have been made in areas crucial to understanding HIV transmission. In the last eight years, great progress has occurred in understanding gay mate sexual behavior in relation to AIDS and HTV infection. Nev- ertheless, even in this research domain, the accuracy of any given set of estimates is open to question, as most studies employ different assessment methodologies with unknown psychometric properties, different time frames, and different types of samples. Although it is accurate to conclude that particular associations and trends have been replicated, the actual population parameters (e.g., means, co- variances, stanciarc3 errors) have not been replicated across studies; therefore, they are not known with any degree of certainty at this time. In this section, we briefly review some of the methodological issues that will continue to concern future researchers, including such issues as the accuracy of self-reported ciata on sexual behav- ior, methodologies for sampling men who have same-gender sexual contacts, and problems associated with the development of reliable survey instruments.

148 ~ UNDERSTANDING SPREAD OF HIV Accuracy of Self-Reported Data on Sexual Behavior In dealing with self-reported behavior, there is always concern about the accuracy of responses.32 Even if a reluctance to answer is over- come with guarantees of anonymity, the question of accuracy re- mains. This is especially true when self-reports cannot be checked against more objective data. The age at onset of sexual activity is a good example: it is an extremely important variable Tom the point of view of risk assessment (for both STDs and unplanned concep- tions), public policy, and program design. Un(lerstan(ling its range in any given population is essential to determining where, for whom, and at what age interventions are required. The question is whether the age at onset of sexual activity can be accurately determined from survey interview data. In one school-basec! stucly of young urban blacks, approximately 90 percent of the mates and 95 percent of the females responded when asked their age at first intercourse (Zabin et al., 1986a). That their answers are credible is supported by two pieces of evidence. First, there are similarities between the overall responses in these groups and responses reported from similar populations elsewhere in the country. Second, there are similarities between the shapes of mate and female curves of sexual activity onset and curves represent- ing pubertal markers for each sex—wet creams for young men and menarche for young women. The two curves peak at the same age for young men; the sexual activity onset curve peaks two years after menarche for young women, which is consistent with observations in similar urban communities. Mott (1985:21-23) has reported, how- ever, that 29 percent of young men and 15 percent of young women in the National Longitudinal Survey33 stated that they were virgins in the 1983 survey but had previously reported (in 1982) that they had experienced sexual intercourse. This kind of discrepancy suggests that the question of how good self-reported data are depends on the degree of accuracy required. If what is needed is a rough marker of early, normative, anti late onset of sexual activity within a group, the data appear good. If the exact year of onset is needed, there is more of a question about accuracy. 32see also the discussion of this issue in Chapter 3. 33The National Longitudinal survey is a recurring survey; the efth-round survey Of youth Aged 14-22 when first interviewed in 1979) studied a probability sample of 6,143 males and 6,078 females during 1983. One major focus of this round of the survey was the study of the relationships between school leaving, fertility, and employment tMott, 1985~.

SEXUAL BEHAVIORS ~ 149 As the example of age at onset of sexual activity indicates, one of the most difficult theoretical aspects of the measurement of human sexual behavior using survey techniques is the problem of "validity"; that is, the deviation of the value obtained by a measurement from the presumed "true" value for the underlying trait. Typically, for most behavioral phenomena, researchers assume that there is a true value and that measurements cleviate from it (either randomly or systematically). For such characteristics as chronological age, ev- iclence other than self-reports can be sought for example, in the historical records provided by birth certificates to vaiiciate the self- reported data. Ancillary studies that gather such independent data can be user! to estimate the magnitude and direction of bias in the self-reported data and to recalibrate the estimates derived from the self-reports to adjust for reporting bias. Even for many sensitive behaviors, official records may be useful: for example, it is possible to gauge the extent of bias and unreliability in reports of offenses like drunk driving by culling arrest records. However, measures that are inherently subjective, such as reports on attitudes and feelings, are not amenable to this type of approach. If someone reports that he or she is "happy," there is no analogue to a check of official records to determine whether the report is accurate. All behaviors (including sexual behaviors) are theoretically oh jective; that is, in theory they could be verified by an observer. Ordinarily, intimate behaviors do not occur in the presence or sight of an observer other than the subject (and the partner, if any). Thus, the vaTiciation of self-reported data on human sexual behav- ior cannot except in the rarest of circumstances proceed in ways that are considered to be appropriate for validating data on other behavioral phenomena.34 Devising alternative procedures to validate measurements that are not amenable to direct verification will re- quire careful thought and investigation—and success is not assured. In this regard, other efforts to validate survey measurements of sum jective phenomena may be informative.35 Clearly, survey estimates of sexual behavior are subject to many of the same nonsampling errors that are well known in other areas of measurement, and some of the models that have been found useful in these areas might also find 34Masters and Johnson's (1966) laboratory studies of human sexual response are one of the rare exceptions. However, their research was intended to study sexual response in a purposely designed, "artificial" environment, rather than in natural settings using a representative population. 35For a summary and review of the literature, see Turner and Martin (1984:Vol. 1, Chaps. 4-6~; see also Beniger (1984), MacKuen (1984), and MacKuen and Turner (1984~.

150 ~ UNDERSTANDING SPREAD OF HIV application here (e.g., Turner, 197S, 1984; Bradburn and SuUman, 1979; Clogg, 1984; Duncan, 1984; Jabine et al., 1984~. One possible approach is to compare changes in sexual behavior with changes in other related phenomena. It may be possible, for example, to construct a convincing validation by demonstrating that an independent series of measurements of change in the incidence of gonorrhea in a population over time could be predicted from a concurrent time series monitoring the self-reported incidence of un- protected sexual contacts with new partners in the same population. Although there are many potential pitfalls to executing a successful validation in this way, the committee believes that the feasibility of using such indirect procedures should be given further, careful consideration. Sampling Gay and Bisexual Men A major problem for research on same-gender sexual contact is the lack of an efficient sampling frame from which to draw random sam- ples of men who have sex with men. Not only are the definitions of "homosexual" and "bisexual" problematic, but the enlistment of community support is a vital first step in any such survey. The ap- proaches taken by various investigative teams confronted with the difficulty of sampling homosexual and bisexual men for surveys on AIDS and HIV are instructive. Before reviewing these approaches, however, it should be noted that practical constraints precluded the use of probability sampling in many of these surveys. Although such constraints are understandable, the committee believes future sur- vey efforts will benefit greatly from the increased use of probability sampling procedures. A common approach taken in many early investigations was the convenience sample drawn from a narrow source, such as private meclical practices (Marmor et al., 1982; Goedert et al., 1985), sexually transmitted disease clinics Chafe et al., 1985), or gay bars and bath houses (McKusick et al., 1985~. Some of these studies have been useful in dating the introduction of HIV into the gay population and in establishing the associations between specific sexual patterns and AIDS and HIV infection. Others have been helpful in pointing out particular aspects of behavior that should be studied. However, using data from these studies to estimate population parameters is unsound. Any group of individuals drawn from treatment sources such as clinics or private practices will have higher rates of most types of physical disorders compared with individuals who are not

SEXUAL BEHAVIORS ~ 151 found in treatment settings. In abolition, those in treatment settings will also have higher rates of the biological and behavioral risk factors associated with illness. Thus, it is impossible to derive valid estimates of, for example, the prevalence of HIV antibody among homosexual men, the incidence of new cases of HIV infection, or the frequency of specific sexual activities from treatment-basecl study groups or from groups of gay men drawn from locations that promote the type of behavior one is interested in studying. An approach to sampling gay and bisexual men that moves a step beyond the convenience sample in rigor is to recruit volunteers through print ads and public notices. This approach has been used to develop entire samples (Deters et al., 1987; Fox et al., 1987), as well as to supplement extant samples of gay men assemblecl in the late 1970s for testing and evaluation of the hepatitis B vaccine (Stevens et al., 1986; Joseph et al., 19874. Although this approach is clearly superior to relying on a single narrow subject source, the samples are not probability samples and numerical results cannot be confidently generalized with known margins of sampling error. It should also be noted that there have not as yet been substantial efforts to systematically assess the differences in subsamples of gay men as a function of their source of recruitment. One steely built systematic differences into the sampling scheme (Martin, 1986a, 1987a; Martin et al., in press). These investigators drew a probability sample of all gay men belonging to at least one gay organization in New York City as of 1985 (response rates were 96 percent for the organizations and 72 percent for recruited individ- uals). The sample was supplemented by non-probability samples of gay respondents drawn from a public health clinic and face-to-face recruitment efforts and by self-selected volunteers. An additional systematic source of selection involved recruitment into the study group through personal referral by those already enrolled. The ra- tionale for this acIdition was to move away from individuals who were directly accessible to the study team and to contact and recruit people from networks in the larger gay community that were more difficult to reach (Martin and Dean, 1985~. The only face-to-face interview study in the United States that employs a probability sample of gay and bisexual men is the San Francisco Men's Health Study (Winkelstein et al., 1987a). A clus- terec] probability sampling of the 19 San Francisco census tracts centering on the Castro district (the area of the city that is most densely populated by gay men and that has the highest incidence of AIDS cases) generated a sample of more than 600 gay men. The

152 ~ UNDERSTANDING SPREAD OF HIV strength of this approach lies in its ability to clerive defensible esti- mates of population parameters; indeed, it could be argued that this approach represents a standard that should be aspired to by other research in this fielcl. It must be noted, however, that the sample only contains men who live in a particular gay enclave of San Fiancisco. It is not representative of men with same-gender sexual preferences who live elsewhere and who may choose to live apart from the gay community. Additional restrictions on the generaTizability of findings from this sample (involving levels of sexual activity, socioeconomic status, race, and age) are imposed by sampling the Castro district. Such restrictions would apply in any sample of a gay neighborhood, including New York City's Greenwich Village or the city of West Hol- Tywoocl, California. Even recognizing that a particular type of gay man constitutes the sample, the response rate of 59 percent obtained by Winkelstein and his group suggests that a particular type of gay man living in the gay section of San Fiancisco may have been willing to identify himself as gay or bisexual to the researchers and to par- ticipate in the study. It would be extremely valuable to know more about the 41 percent of the sample who were nonresponders. In sum, although the use of probability samples is scientifically preferable to any other method, it does not guarantee a representative sample: the limitations imposed by the sampling frame itself and by nonresponse must be acknowledgecl.36 The sample from the Castro reported a preponderance of men who stated that their sexual partners were exclusively male. More- over, Winkelstein and colleagues (1987b) reported a low rate of het- erosexual partnering among the men in their sample identified as bisexual (Table 2-9~. This result can be usefully contrasted to the finding from the national population surveys, which indicated that a substantial fraction of men with histories of adult homosexual con- tact was currently or previously married. There are several possible explanations for the apparent divergence. For example, the national population surveys should be finding more "closete(l" men than are found in studies focusing on men who reside in gay-identifiec! com- munities. Similarly, recent contacts may be evidence of a different 36Although the investigators did not obtain information on nonparticipants, they did compare the demographic characteristics of the survey sample with the characteristics of residents of the tracts as reported in the 1980 census. This analysis indicated a modest underrepresentation (-8.2 percentage points) of men aged 25-29 and an overrepresenta- tion (+8.9 percentage points) of men aged 35-44. The most striking divergence of the sample from the census occurred for education: 89.8 percent of the sample reported one or more years of college; the census estimate for these tracts was 24.6 percentage points lower.

SEXUAL BEHAVIORS | 153 TABLE 2-9 Numbers and Percentages of Male and Female Sexual Partners of Homosexual, Bisexual, and Heterosexual Men Residing in the 19 Census Tracts Centering on the Castro District of San Francisco, January-june 1984 Homosexual Bisexual Heterosexual No. of No. (~o) of No. (~o) of No. (%) of No. (%) of Partners Male Partners Male Partners Female Partners Female Partners 0 46 (7.2) 24 (13.9) 117 (67.6) 12 (5.7) 1 137 (21.4) 36 (20.8) 27 (15.6) 99 (46.7) 2-4 182 (28.4) 44 (25.4) 23 (13.3) 75 (35.4) 5-9 104 (16.2) 32 (18.5) 2 (1.2) 20 (9.4) 10 + 172 (26.8) 37 (21.4) 4 (2.3) 6 (2.8) Total 641 (100.0) 173 (100.0) 173 (100.0) 212 (100.0) NOTE: Six subjects were not included because of missing data. SOURCE: Winkelstein et al. (1987b). Copyright, 1987, American Medical Association. (and more consistent) pattern than can be cletermined from lifetime contacts. Clearly, however, more data will be required to determine a plausible interpretation of this apparent divergence in findings. Developing Reliable Survey Instruments Measurement Time Frames Another methoclological problem that makes cross-study compar- isons nearly meaningless is the lack of consistent time frames as- sociated with particular assessment instruments. In estimating the number of sexual partners of gay men, for example, some studies fo- cusect on a "typical" month in a particular year, multiplied that value by 12 (for the yearly total), and then multiplied that value by the number of years of being sexually active to produce a lifetime total (Marmor et al., 1982; Jaffe et al., 1983~. Other studies focused on a one-month period, comparing that number to the number reported for the same month in the previous year (McKusick et al., 1985~. Still others focused on a one-year period and generated estimates based on 12 months (Martin, 1987a). It is impossible to make direct comparisons of estimates that were derived in such diverse ways, and it should be noted that problems of accurate recall can be substantial when respondents are asked to make estimates covering a 12-month period (see Jabine et al., 1985~.

154 ~ UNDERSTANDING SPREAD OF HIV This problem is even more sharply illustrated in estimates of the occurrence or nonoccurrence of a particular behavior (e.g., monog- amy, celibacy, abstinence from intercourse). For such analyses, the time frame covered by the assessment is essential to an understanding of the results: clearly, monogamy for one month is quite different from monogamy for one year. Interviewer Versus Self-Administered Assessments One reason assessment approaches may vary so greatly is that some studies use interviewer-administered questionnaires (Martin, 1987a; Winkelstein et al., 1987c; Fox et al., 1987; McCusker et al., l98Sb) while others use self-administered questionnaires (Marmor et al., 1982; McKusick et al., 1985; Joseph et al., 1987~. Given the com- plexity of sexual behavior and the numerous contingency questions that are required in the event of an affirmative answer, it may be in- appropriate to employ self-administered assessment questionnaires. It must be recognized nonetheless that accurate reporting of sexual behaviors in face-to-face interviews may be embarrassing for some respondents. This may in turn cause some respondents to conceal important aspects of their sexual histories. There is some evidence (e.g., Klassen et al., in press) suggesting that respondents are more likely to report sensitive sexual behaviors on self-administered ques- tionnaires, but methodological research on survey measurements of other sensitive topics is equivocal (see, e.g., Bra(lburn and Su(lman, 1979:Table 2~. Although no firm conclusions can be drawn, it is clear that further methodological research on the validity and reliability of alternative interview techniques is needled. Behavioral Specificity Behavioral specificity is a prerequisite for all research on sexual be- havior and AIDS. Use of overly complex constructs such as "safer sex" in assessment protocols or in reporting results can obscure the behavioral phenomena of most interest and risk misunderstandings about the exact meaning of the measurements. The problem is demonstrates! in the lack of clarity that emerges with respect to risk taking in reports by Martin (1986a) and Stall and colleagues (1986~. These investigators used composite indicators of risk rather than specific sexual behaviors as the outcomes of interest, making interpretation of the fin(lings problematic. Another issue involves specification of sexual behaviors in which an individual may act as

SEXUAL BEHAVIORS ~ 155 the inserter or the receiver (Research and Decisions Corp., 1985~. This is an especially important problem with respect to homosexual sex, since men can readily play both receptive and insertive roles during sex. Thus, one needs to know not only the type of sex act but the role that was played (e.g., receptive anal intercourse). Reliability and Validity of Measures It shouIc! also be noted that very few studies in this field have reported ciata on the reliability and validity of their sexual behavior measures. Martin (in press) reported test-retest reliability, as did Saltzman and colleagues (1987~; however, no such reports can be found in other major epidemiological stucTies of gay mate sexual behavior ant] AIDS. In the face of the epidemic, conducting and reporting studies has assumed a higher priority than the refinement of methoclologies; now, however, it is time to step back and assess the limitations of the studies that have been conducted! so that sounder efforts can be mounted in the future. Sample Coverage Although many studies have demonstrated declines in risk-associated sexual behaviors among men who have sex with other men, they do so, as noted previously, among only one segment of the total popula- tion: self-iclentified gay men and members of local gay communities. Missing (as they are from most sex research) are men with same- gender sexual preferences who are members of minority ethnic and racial groups, who are from the working class, or who are poor; also missing are men from rural areas anti smaller cities who primarily have sex with men, as well as men who have sex with both men and women. By using gay communities as sampling sites, these stuciles have probably Tocatecl the areas of the country with the highest levels of sexually transmitted infection, but in doing so, they have missed other populations about which, consequently, very little is known. Lack of knowledge is particularly acute regarding men with same- gencler sexual preferences who belong to racial ant! minority groups in which different cultural standards may obtain about sex between men. The work of Carrier (1976) suggests that, among Latino groups, sex between men often occurs along strongly stereotyped lines in which one partner is consistently the active (the inserter) and the other the passive (the insertee). The active partner does not consoler himself to be homosexual, and anal intercourse may occur both with

156 ~ UNDERSTANDING SPREAD OF HIV mate and female partners. In other minority communities, casual sex for pay may occur with male or female partners with relative indifference. There is also evidence in minority communities of wholly self-contained pairs and groups of men who practice sex only with men but have little or no contact with visible gay communities. Also important to a complete assessment of the risk of HTV transmission among people with same-gencler sexual preferences are studies of men who have sex with both men and women, following quite different social-psychological scripts to organize their experi- ence (Gagnon, 1977~. Many young men have a few sexual experiences with other men for pay; a few have many experiences. The sexual patterns of such "hustlers" are quite varied, ranging from the delin- quent boy who has sex primarily with young women while being paid for sex with men, to the young man who has sex exclusively with men for pay (A. J. Reiss, 1961~. The "average" hustler probably does not exist, and patterns of sex for pay among men probably vary enormously, clepending on the local community. Similarly, men who have secret sexual experiences with other men in addition to a heterosexual marriage are also bisexual but in quite a different sense than are men who have sex with other men only in prison or when in other all-maTe groups At. Humphreys, 1970; Gagnon and Simon, 1973~. Of course, such men are potential bridges between heterosexual and homosexual partners. These populations are often quite difficult to locate when net- works are sampled starting with gay-iclentified men, although careful ethnographic studies may finch some networks that include them. Work with (lelinquent boys, studies of "bright-light" areas (e.g., Times Square in New York City), and research efforts in minority communities may uncover examples of these patterns. Other middle- cIass bisexuals may be found through studies of swingers' clubs. None of these procedures, however, can generate a sample in a way that will allow estimates based on it to be generalized to a larger population. Little research—even studies of those who identify themselves as gay men ant! lesbians has ventured outside of urban communities in which there are concentrations of potential respondents. As a result, understanding of the life of gay men and lesbians is restricted to a few contexts, despite substantial evidence that, even within the United States, the sexual lives and networks of gay men ant! lesbians differ from community to community (E. White, 1980~. As more reliable national samples of persons with same-gender sexual experience become available, they will allow far better judgments

SEXUAL BEHAVIORS ~ 157 to be made about the information that has been gathered on more restricted populations (Davies, 1986~. Ultimately, these data may be particularly important in studying the linkages among sexual strata that is, fitting together the experiences of gay men, lesbians, bisexuals, and heterosexuals and providing a historical perspective for studying social change in same-gender sexual behaviors. ANTHROPOLOGY'S PERSPECTIVE ON HUMAN SEXUAL BEHAVIOR Our discussion thus far has dealt entirely with research carried out through interviews that are usually conducted by means of a survey (and typically with a standard questionnaire). Although the pioneers of this method of sex research were recruited from many different fields (Kinsey, as previously noted, was a biologist), this research tradition has been sustained largely by persons trained in sociology, demography, psychology, and survey research. A rather different tradition of studying human sexual behavior arises within the field of anthropology. The methods of anthropol- ogy, and of ethnography in particular, offer important alternative perspectives for understanding sexual behavior. In circumstances in which other techniques cannot be used because of constraints on resources or the sensitivities of the population being studied, the information provided by ethnographers may be the only information that can be collected. In this section, we briefly review the anthropological literature on human sexual behavior and discuss ways in which this research approach is being used in contemporary studies of sexual behavior and behavioral change relater! to AIDS. From 1929 to the 1970s When MaTinowski published his pioneering work The Sexual Life of Savages in 1929, Havelock Ellis, a well-known theorist on sex- ual behavior, conficlently predicted! the arrival of a new era in the study of human sexual behavior. Anglo-Saxon puritanism of the nineteenth century was now cast aside, and twentieth-century inves- tigators would! no longer consider unfamiliar sexual customs to be shocking, disgusting, or even unspeakable. People were also learning to view their own sex taboos a little less solemnly (Ellis, 1929:xiii). Nonetheless, detailed anthropological research on sexual conduct in non-Western cultures is something of a recent phenomenon. A few

158 ~ UNDERSTANDING SPREAD OF HIV anthropologists of European descent had showed an early interest in the field (Schapera, 1941; Layers, 1942, 1959; E1win, 1947~; in a~l- dition, an American publication, Patterns of Sexual Behavior (Fore! and Beach, 1951), provided a compendium of such exotic data as the preferred locations of intercourse, standards of female beauty, and positions of intercourse in various cultures. Anthropologists, how- ever, gave little attention to the expression and meaning of sexuality in different social and historical contexts. As in other branches of the social sciences, there was virtually no research that could contribute to general theories of human sexual development and gender identity. Yet sex was not an entirely forbidclen topic. The fear of "over- population" in the so-called underdeveloped countries and the prolif- eration of birth control studies in the 1950s and 1960s captured the attention of anthropologists who were interested in various aspects of population dynamics. Anthropological studies gave some preci- sion to the debate about whether it is the large size of families that explains their poverty or whether people have large families because they are poor (Mam(lani, 1972~. Fine-grained research pointed to the economic value of children, especially adolescent sons, as con- tributors to family income and as protectors of family property and of elderly or widowed parents later in life (B. White, 1975; Cain, 1977~. The economic interests in producing children were shown to vary somewhat by class and in different historical periods. These studies gave rise to a research tradition that defined the political and economic contexts of changing sexual practices, a tradition that continues to the present. Studies of the changes in reproductive be- havior associated with the recent shift from low to high levels of fertility in Thailand (Knocle] et al., 1984) and of the contrasts in the demographic transition experienced by the gentry, artisans, and peasants in Sicily from 1850 to the present (Schneider and Schneider, 1984) are part of that research tradition. A different research approach was followed by anthropologists with an interest in symbolism. In the 1960s, many anthropologists viewed the body as a metaphor for society (Douglas, 1966~. Food taboos, the eating ant! sharing of food, and rules about sexual ac- tivities were thus seen as statements, in each location, about the body politic. Throughout the 1970s, this field of enquiry gained new energy and intellectual direction from feminist scholars who were interested in the power implications of accepted notions of gender and sexuality in Western ant! non-Western contexts (Reiter, 1975; MacCormack and Strathern, 1980; for a review essay on feminist publications in this period, see Vicinus [1982~. "Male," "female,"

SEXUAL BEHAVIORS ~ 159 "sex," anti "reproduction" were shown to have different meanings in any given culture and had to be understood within a larger context of cultural beliefs, classifications, and assumptions. Questions about the meaning of sex as erotic techniques, medical facts, or Freudian psychology were said to be embeclde(1 in matters of rank, prestige, and the economy in kinship-based societies (Ortner and Whitehead, 1981~. As MaTinowski (1929:xxlli) observed earlier in regard to South Sea IsTanclers, "sex is not a mere physiological transaction.... It dominates in fact almost every aspect of culture. Sex, in its widest meaning . . . is rather a sociological ant! cultural force than a mere bodily relation of two individuals." Throughout the 1970s, anthropologists continued to examine theoretical issues related to the social construction of gender, but they paid little attention to actual sexual behavior, viewing gender and sexuality as conceptually linked. Although research in the 1980s initially continued along this path, it has gradually become clear that gender and sexuality should be analytically separates! to reflect more accurately their separate social existence (G. Rubin, 1984; Vance, 1984~. The 1980s Prior to AIDS As Malinowski suggests, in many non-Western cultures, sex provides the template for social life, resulting in the formation of gender identities and psychosexual development that differ from those of the West. In the West, life stages tend to be defined by steps in education, work, or career; yet in Bangla(lesh, to take one example, there are nine accepted life stages that are closely Inked to expectations about sexual behavior and reproduction. Moreover, as might be anticipated in a culture that leans heavily on biological differences to construct distinctions in gender, the expected behavior of Bangladeshi men and women differs greatly. Preadolescence (ages 11-12), for example, is recognized as a distinct stage more for girls than for boys because of the importance of a girl's behavior to her reputation and that of her family. A girt is expected to learn proper female decorum before the end of this period so she can play the female part well once puberty sets in. According to local moral standards, late adolescence (ages 16-20) is a dangerous stage of life, applying more to mates than to females because mates usually remain unmarried. A boy of this age works to contribute to family income, unless he is at school, but it is considered disgraceful if an adolescent female has to work outside the home, even in the poorest families. Gender role expectations

160 ~ UNDERSTANDING SPREAD OF HIV become exaggerated at this time. It is not considered shameful for a young man to look at a young woman with a sensuous eye; on the contrary the young woman bears the blame. Moreover, boys have a period of some years to establish their identity before marriage, while girls are thrust into a quasi-aclult—and subservient role in their teens (Aziz and Maloney, 1985:48-60~. The Bangladeshi life scheme, like those of other cultures in South Asia, is constructed without reference to Freud and thus lacks a concept of infantile sexuality or an analysis of prepubertal sexual socialization. In such an environment, Erikson's (1964) eight-stage development cycle, with its two opposing qualities to be resolved in each stage, emerges as quaintly Eurocentric. South Asian life schemes are not premised on conflict resolution within life stages but proceed ladder-like, bicIding the individual to find his or her place in the total universe (Aziz and Maloney, 1985~. The sexual "revolution" of the 1970s and the continued decon- struction of gender assumptions provoked a new wave of enquiry into the sexual behavior of "others." This research further confirmed the fact that sexuality is astonishingly plastic and variable in its expression from culture to culture. As Gregor (1985:3) notes in his study of sexuality among an Amazonian group, the Mehinaku, " into purported universals of sexual behavior are unquestioned, and only a few seem reasonably well documented. Among the best established of these is that males have a higher level of sexual interest than do females." Evidence for the plasticity of sexual behaviors came especially from studies in New Guinea. Institutionalized same-gender relation- ships among men, reporter! by earlier investigators, were now exam- ined in light of contemporary psychoanalytic and psychosocial theo- ries of human development. Ritualized homosexual behavior among men, reliably reported from perhaps 10-20 percent of all Melane- sian groups (Herds, 1984), indicated that these activities were not a deviant form of cultural behavior. (Suggestions of same-gender relationships among women have been glancingly reported for the re- gion, but the femaTe-femaTe erotic relationship remains a historically un(lerinvestigated topic.) The organization of sexual practices and the formation of gen- er identities in the small "homosexual" societies of New Guinea are integral to the systems of production and reproduction in these societies. Among the Sambia of Papua New Guinea, for example, homosexual practices begin at ages 7-10, when all young boys are taken from their mothers to be initiates] into the male cult. For some

SEXUAL BEHAVIORS ~ 161 10-15 years, they engage in erotic practices, first as felIator, ingesting the semen of an older bachelor, and then as felIated or semen flour. At the same time, the boys and youths must avoid women or be punished, as elders teach them that semen is the sole physical and psychic path to manhood. The cultural gift of semen is said to be the only way older men can ensure the growth, development, and masculinity of members of their sex. In the Sambian culture, there is much talk of growth, physical attractiveness, and the formation of the intellect but no word that translates as "homosexual." The pattern of same-gender sexual activity and avoidance of women continues until marriage, after which the young men may follow "bisexual" be- haviors for some years. With fatherhood, however, all same-gender activity is expected to cease. The final outcome, exclusive hetero- sexual activity, brings Sambia mates to the endpoint of a prescribed erotic path to adulthood! (Herds, 1981~. Descriptions of the cultural life of the Sambia and of other "ho- mosexual" groups in Papua New Guinea challenge Westerners to reevaluate standarcI generalizations about adolescence and sexual development. Socially sanctioned sexual behaviors in these non- Western cultures differ across the region and include oral sex, anal intercourse, and the application of semen (which is considered to be a life force and is rubbed into incisions on the initiates' bocI- ies) (Lindenbaum, 1987~. Because different groups have generally disparaging views about the sexual activities of their neighbors, vari- ations in these practices involve the creation of ethnic identity within a regional complex. As Kelly (1977:16) comments about the peoples of the Great Papuan Plateau: "Inasmuch as the members of each tribe become men in different ways, they are predominantly different kinds of men, culturally distinct beings at the most fundamental level." Like speech, religion, race, food habits, and clothing, then, sexual conduct appears to provi(le a highly charged basis for ethnic division anc! discrimination. Although the expressions of homosexual behavior in Papua New Guinea vary across the region, they do not belong to a separate sphere of cultural activity. Differing among themselves, they nevertheless clisplay a profile of sharecT symbolic themes, a sense of variation and permutation on a common Melanesian fund of sociosexual behavior and social organization (I,in(lenbaum, 1984~. Within ant! beyond the geographic regions in which ritualized "homosexuality" occurs, men give ritual attention to bol(ly fluids (the expulsion of blood anti the infusion of semen), the injection of various substances to promote

162 ~ UNDERSTANDING SPREAD OF HIV masculine growth, the life-ciraining dangers of heterosexual inter- course, and the fear of women who are menstruating. The Melane- sian ciata indicate that "homosexuality" ant! "heterosexuality" are related cultural constructs. Anthropological Research Since AIDS Continuer! attention to gender relations, a resurgence of interest in psychoanalysis, and a focus within medical anthropology on sex- ually transmitted disease especially AIDS have directed anthro- pologists to ask new questions.37 Many research projects are now concerned with the cultural construction of sexual practices relevant to HIV transmission. For example, a preliminary study among Mex- icans of rural origin in northern Mexico describes transvestite "ho- mosexuals" who are symbolically construed as women in numerous contexts. On festive occasions, they dress as women, adopt female names, and use female pronouns to refer to each other. As symbolic women, they have sexual relations with other men who are often married and who in local terms are considered heterosexual. The married men view the transvestites as sexual surrogates for "real" women. Women themselves demonstrate greater tolerance for mate sexual encounters with transvestites than with female prostitutes or concubines because there is less risk of desertion or of diminished eco- nomic support for the family. Standard interviews and questionnaires that are insensitive to such culturally constructed sexual practices would overlook a form of mate "bisexuality" that is normalized and rendered socially invisible but that may be an important avenue for HIV transmission (Alonso and Koreck, 1988~. Recent enquiries into the meaning of same-gender sexual be- haviors among Afro-American men in Baltimore (Pounds, 1987), Chicanos in Texas and Arizona (Mate and Jorquez, 1988), men in Nicaragua (Lancaster, 1988) and urban Brazil (Parker, 1987), and "closeted" homosexuals and gay men in New York City (Kochems, 1987b) reveal a range of male identities, differing from community to community. Each study emphasizes that self-identification must be taken into account so that key differences in the cultural construc- tion and experience of sexual practice are not obscured. In many moor an account of the feminist shift in focus during this period, see Rich (1988~. Rich points to the broad range of factors reshaping female sexuality in the 1980s: reactions to AIDS, which have revived homophobia; the "second wave" of feminists becoming moth- ers in the 1980s (leading to the notional rejoining of sexuality and reproduction); and the implications of conservative/liberal political skirmishes over the control of sexuality (the attacks on abortion, day-care centers, and civil rights).

SEXUAL BEHAVIORS ~ 163 accounts, for example, men who have intercourse with other men do not consider themselves to be bisexual. In addition, as Alonso and Koreck (1988) suggest, groups of different national and regional ori- gins, as well as ethnic and class affiliations, should not be subsumed into an inclusive category (e.g., "Hispanics. The same might also be true for other population categories (e.g., women, blacks, and Asians). Another line of current investigation centers on the knowledge, beliefs, and attitudes about AIDS and the perception of risk in various populations for example, in Rwanda (Feldman et al., 1987), among gay and lesbian teenagers in Chicago (Herds, n.~.), and in a Midwestern college population.38 Also under investigation are gender differences in knowledge about AIDS and sexual behaviors (Strunin and Hingson, 1987~. In addition, the cultural impact of AIDS testing has been evaluated (McCombie, 1986~. The studies that have been discussed thus far are a natural ex- tension of the symbolic anthropology of the 1970s and early l980s with its emphasis on meaning and interpretation. The shape of the research, however, is molder! by current knowledge of the spread of AIDS ant! HIV infection and by the value of anthropological find- ings to epidemiology or to health administration. Ethnographies published before the advent of AIDS have also been culled for de- scriptions of the social factors that are relevant to the spread of the virus. The African literature provides detailed accounts of sexual relations and marriage, ritual and therapeutic activities involving blood (cTitoridectomy, circumcision, scarification, incisions for pro- tection, tooth removal, injections from indigenous and nonindigenous practitioners), as well as descriptions of the migration of populations toward urban centers or across regions (see Brokensha et al. [1987], for a survey of relevant studies; see also Hrdy [1987~. This material can inform future epidemiological research, but the accounts need updating as well as enhancement through the inclusion of material about such key behaviors as "homosexuality," "bisexuality," multiple sexual partnerships, drug use, and the use of health care, none of which has been well stuclied in the past. AIDS has also drawn some anthropologists into the field of medi- cal anthropology, in which theories are tested and applied. A number of anthropologists are now working in outreach education programs with gay men's advocacy groups (Kochems, 1987a), in programs for 38M. D. Quam, Department of Sociology and Anthropology, Sangamon State University, personal communication (1988~.

164 ~ UNDERSTANDING SPREAD OF HIV self-help intervention with female IV drug users or female sexual part- ners of IV drug users (Worth, 1988), in the evaluation of community education programs (Harder et al., 1987), in programs serving mate prostitutes (Fisher et al., 1982~39 and female prostitutes (Schedlin, 1987; Sterk and Leonard, 1988) in the United States, and in studies of multiple-partner relationships in Central Africa (Schoepf, 1988~. In addition, anthropologists continue to provide information about beliefs and behaviors that have not been elicited by other research methods and to work more closely with epidemiologists to describe and analyze the spread of illness, which is a cultural ant! social phe- nomenon (Feldman and Johnson, 1986; Gorman, 1986; Stall et al., 1986; Flowers, 1988~. In studying the effects of the disease on specific populations, anthropologists and historians also point to epidemics as a time of testing for political, economic, social, and cultural insti- tutions (Hartwig and Patterson, 1978; Lindenbaum, 1979; Brandt, 1987~. CONCLUSIONS AND RECOMMENDATIONS The AIDS epidemic has forced American society to examine itself and its behaviors, institutions, and practices. In no area has that examination been more tortuous than in the realm of sexual behav- ior. The links between HIV transmission and sexual behavior have focused attention on current knowlecige of sexual practices, which has been found to be fragmentary and unreliable. The changes that have occurred in the last few decades in the way Americans conduct their sexual lives are not reflected in what little research there is on sex. Consequently, attempts are being made to alter the course of what is mainly an STD epidemic without the benefit of a sound unclerstanding of the behaviors that spread it—an understanding that is essential to the design of educational efforts and intervention strategies. To correct this situation and slow the further spread of HIV infection, the committee believes it is imperative to extend and im- prove the quality of information available on sexual behavior. Basic behavioral research has not received strong support in this country; at present, sex research is barely represented as an activity in federal research agencies. In the past, some sex research was conducted by the government, but it was oriented toward the achievement of a 39T. Marotta, Urban and Rural Systems Associates, San Francisco, personal communi- cation (1988~.

SEXUAL BEHAVIORS ~ 165 specific goal (generally, preventing teenage pregnancies) rather than the collection of basic behavioral data. Although the committee finds the past mission-orientec3 research efforts of the government to be a valuable and necessary part of the federal research portfolio, there are substantial gaps in basic knowledge that need to be fillet! if the country is to contain the spread of the AIDS epidemic. The committee recommends that the Public Health Service support vigorous programs of basic social ant! behavioral research on human sexual behavior, particularly through such agencies as the National Institutes of Health; the Alcohol, Drug Abuse, and Mental Health Administration; and the Centers for Disease Control. If AIDS prevention programs are to be targeted in a more effec- tive and efficient manner, more must be known about those people who are at risk: who they are, where to reach them, and the be- haviors they engage in that put them at risk. The committee recommencis that data be collected to estimate the preva- lence of the sexual risk-taking behaviors associated with the acquisition ant} spread! of HIV infection in various popula- tions, including those at higher ant! lower risk. Similar data are needed to understand the variability of these behaviors across subpopulations and among individuals. Another element of the sexual behavior equation must also be considered. Sexual conduct is influenced by a variety of factors, including cultural norms and values, physical capabilities, and op- portunity. Therefore, the committee recommencis that high priority be given to studies of the social ant! societal con- texts of sexual behaviors. Furthermore, because sexual behav- ior is dynamic evolving and changing over the course of history and throughout the sexually active period of an individual's life a "snapshot" of risk-associated behaviors will not be sufficient. The committee recommends that funding be provided (and con- tinuec! over time) to support prospective longitudinal studies of sexual behavior. Such studies will enrich our unclerstanding of changes in behavior and help to detect emerging problems. The committee recognizes that a request for more basic behav- ioral research will require a heretofore absent long-term commitment to this type of research. Sexually transmitted diseases, unwanted and unplanned pregnancies, and the medical and social consequences of drug use are Tong-standing, serious problems in our society that re- quire and deserve a Tong-term commitment. The country is now paying the costs that result when prospective studies are interrupted

166 ~ UNDERSTANDING SPREAD OF HIV and research programs are subject to "feast-or-famine" cycles of sup- port. At the moment of crisis, the United States lacks critically important prospective studies and well-trained cadres of researchers. In addition to basic behavioral studies, the revised set of re- search priorities the committee endorses includes more targeted in- vestigations. Thus, the committee recommends that the Pub- lic Health Service support research in those subsets of the population that are at increaser} risk of HIV infection. Such research should include prostitutes and their clients, minorities (mi- nority women and minority gay men and lesbians), lesbians of all ages, young gay men, gay men living outside the epicenters of the epidemic, socially vulnerable adolescents, the different groups that make up the heterogeneous TV drug-using population, and non-TV drug-using sexual partners of {V drug users. Female prostitutes are a population of particular interest. Prosti- tutes are at great risk of HIV infection because of their large numbers of sexual partners, their increased likelihoo(1 of contracting another STD (a potential cofactor in the spread! of HIV), their association with {V drug users, and their own use of IV drugs. Studies of the recruitment, working conditions, social relations, sexual practices, lrug-use patterns, condom usage, fertility patterns, and personal lives of female prostitutes are quite rare, particularly studies that yield quantifiable results. Research on these factors needs to be undertaken in various locations and with women who function in different kinds of prostitution. One important reason for such stud- ies is that customers of prostitutes are a potential bridge for HIV infection into the general heterosexual female population, a group that may currently be at relatively low risk. The social backgrounds and social networks of mate clients should be carefully examined, in addition to seeking answers to the obvious questions about their fre- quency of prostitute contact, the types of sexual behaviors in which they engage with prostitutes, and their use of condoms. The AIDS epidemic has also revealed the intricate relationship that exists between sexual behavior and drug use. The commit- tee notes that alcohol and drug use have been linked to increases in sexual behaviors that risk HIV transmission. The committee recommencis immediate steps to close the vast gaps in our knowledge of the relationship of sexual behavior and drug and alcohol use. Such steps should include developing a better un- derstanding of the variation in drug and alcohol use within subgroups of the population, the effect of alcohol and drug use on the initiation of sexual behaviors that risk HIV transmission, the conditions and

SEXUAL BEHAVIORS ~ 167 antecedents surrounding their initiation, and the actions that might be taken to interrupt such a dangerous chain of events. Success in carrying out many of the committee's recommenda- tions hinges on knowing far more than is now known about how to identify and elicit information from prostitutes, {V drug users, and other groups that currently exist at the margins of our society. Knowledge is needled about how to follow these individuals over time in the interests of better evidence and about effective data collection methodologies. The committee recommends that resources be invested! in methodological research to clevelop better pro- cedures to obtain information from harcI-t~reach groups. In particular, support is needed to study appropriate methods for counting the hard to count, to elicit their cooperation in data col- lection and randomized experimental intervention programs, and to study mechanisms for obtaining valid information about sensitive (and sometimes illicit) behaviors that occur in the contexts of differ- ent cultural and language groups. An area of interest related to information on the spread of HIV ant! AIDS is the somewhat fragmentary state of statistics on STDs. Underreporting is known to be quite common (particularly for cases diagnosed by private physicians), and this situation may have been exacerbated in recent years by the diversion of public health resources from tracking syphilis and gonorrhea to AIDS (thereby reducing the numbers of new cases of gonorrhea and syphillis that are counted). A reliable system of statistics on STDs other than AIDS could play an important role in improving our understanding of the course of the AIDS epidemic. Other things being equal, transmission rates for other STDs should respond to the same behavioral interventions that are being designed to reduce the transmission of HIV infection. Because other STDs produce reportable infection rapidly, they might provide a leaching indicator for HIV incidence rates. Data on STDs might also be useful for validating time-series measurements derivecl from surveys of indiviclual sexual behavior. The committee rec- ommends that an independent review of STD data collection systems be undertaken ant! sufficient resources provided to undertake any improvements that may be required. One intervention strategy whose implementation is efficacious in the prevention of both STDs and HIV infection is the use of condoms (and spermicides), a practice that is regularly recommended to re- duce the risk of HIV transmission. Little is known, however, about the effectiveness of these methods in actual use. Condom failure rates for contraception are known to vary, with some subsets of users

168 ~ UNDERSTANDING SPREAD OF HIV experiencing high failure rates. The committee believes that research is needed to understand! the barriers to the use of condoms and sper- micides and the factors associated with their improper use. The committee recommencts that the Public Health Service im- mecliately begin a research program to determine the extent to which the use of condoms ant! spermicicles recluces the risk of HIV transmission. This program should include investiga- tions of the current use of these products, how that use might be moclifiecI, ancI- equally important how these products themselves may be mollifier} to encourage uses compatible with human skills and dispositions. One part of this research program shouIc! determine whether men and women know how to use condoms effectively and the extent to which they are used reg- ularly. The results of this research should be made available in a timely fashion to those who are designing and implementing AIDS prevention programs. Biomedical research on HIV infection and AIDS often requires gathering behavioral data from populations that are both hard to reach and from whom it is difficult to gather reliable, valid data. Careful attention needs to be paid to the difficulties of gathering such data, both for the sake of the behavioral data themselves (and the uses made of this information) and because the interpretation of biomedical data often depends on them.The committee recom- mencts a concerted! effort to upgrade and stanciarclize (when possible ant} desirable) the procedures used to gather behav- ioral data in clinical and biomedical research settings. Re- sources should be made available to ensure that the best social and behavioral science practices and instrumentation are widely available to all scientists conducting relevant research, including those who are studying biomedical topics such as the natural history of HIV infec- tion. The committee also recommends that funding agencies, both public ant! private, encourage the sharing of data rel- evant to HIV infection and AIDS that have been gathered by federal ant! extramural researchers, within the limits set by scientific priority and conficlentiality. To facilitate such sharing, the committee recommends that a data archive be established to support secondary analyses of these data. Finally, the committee observes that two of the important com- ponents of any strategy for containment of the AIDS epidemic no longer require more research but should be acted on immediately. Simply put, in the face of the spread of a deadly infectious disease that is transmitted by sexual behaviors, there should be no barriers

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