Introduction

This paper examines why people whose behavior is likely to expose them to HIV (the virus that causes AIDS) either use or reject using condoms. Sex partners and offspring of injection drug users constitute the fastest growing group of AIDS patients. Pregnant women and newborns are expected to experience the greatest impact of AIDS in the 1990s.1 In New York and New Jersey, AIDS has already become the leading killer of black women between 15 and 44 years old.2

Globally, AIDS prevention programs have pro-moted condoms to prevent the sexual transmission of HIV.3 Yet it has been recognized that women need techniques that women can control for preventing the sexual transmission of HIV.4

Our major finding reiterates that campaigning for condom use is not an expedient strategy for decelerating the AIDS epidemic. It is problematic to formulate an effective appeal to persuade people to use condoms because motives for consenting or refusing to use condoms are so diverse. Why individuals will adopt condom use is not predictable. The same event that prompts one individual to start using condoms may impel another to stop. We will detail several recurring paradoxes that surround the use of condoms.

There are numerous factors which influence the decision whether to use condoms. Our discussion will focus on: male cooperation; intimacy; procreation; death defiance; future thinking; responsibility to oneself and others, and a sense of community.

Rationale for the Study and Methodology

Earlier reports from an education campaign by CHOWS (Community Health Outreach Workers) at Youth Environment Study/MidCity in San Francisco demonstrated that 80% of injection drug users reported using bleach to clean their needles.5 But CHOWS' warning that HIV is sexually transmitted was met with a different response. Condom use rates around 30% were previously reported for heterosexuals engaging in risk behaviors.6 Although the latter rate compared favorably with other AIDS demonstration projects funded by the National Institute on Drug Abuse, it is insufficient for diverting HIV infection from this jeopardized population.

Our ethnographic study primarily involved drug injectors or heterosexual partners of drug injectors who were enrolled in a counseling program for couples at Youth Environment/MidCity Consortium to Combat AIDS ('YES/ MidCity) during the first few months of 1990. Case histories were also provided by CHOWS and counselors from California's state-wide Heterosexual Partners Study. A total of approximately 50 individuals were either interviewed or their case histories were reviewed. In-depth, focused interviews ranged from a half hour to one and a half hours.

Condoms and Contradictions

Noncompliance with recommended use of condoms is widespread among heterosexuals. Disdain for using condoms is certainly not limited to those whose behavior flirts with exposure to HIV.7 Paradoxically, many YES/ MidCity clients who decline to use condoms despite their own high-risk behavior, insist that it is important to continue the campaign to convince people to use condoms. They emphasize their certainty that more people are using condoms than prior to YES/MidCity's efforts to popularize their use.
Ironically, many of these same individuals who steadfastly — or even violently — refuse to use condoms in their own sexual practices, will act on their belief that free distribution of condoms should continue. One woman who is an occasional heroin user describes her partner's behavior:

We have big bags of condoms around. If friends come over, he'll pass out condoms. But he won't use them! Sometimes his friends already be carrying condoms. His friends think about the AIDS thing and talk about it. He don't. We have all kinds of [condoms]. All colors. And it still don't matter.

Male Cooperation: Equality Within the Relationship

Overwhelmingly, it appears that it is men who make the decision whether condoms will be used in heterosexual relationships. Over and over, we hear that women will acquiesce to their male partner's choice. The exception is commercial sex transactions. Among all groups, prostitutes are most likely to require condoms. As prostitutes, women are more likely to be in control of sexual decision-making, or, in other words, to negotiate the price of risk-taking.8

Yet CHOWS say that prostitutes routinely admit that when they are experiencing intense withdrawal symptoms ("dope-sickness"), they will forego using condoms if a client ("trick") refuses to use one. Prostitutes also state that if a trick offers enough money, they can be persuaded not to insist on condoms. More prostitutes who are injection drug users (IDUs) are being infected by the sexual transmission of HIV than prostitutes who are not IDUs.9

Drug-using women who act as mistresses may assess how much their "Sugar Daddy" is willing to play "daddy" to their children when they decide whether they will require them to use a condom. Playing daddy may entail renting a video for the children or taking them out for fast food. If they fight over the issue, the woman may demand, "Give me the money and use the condom."

In addition to relationships based on the explicit exchange of sex for money, Worth also specifies that relative sexual equality must exist for women to be able to introduce condom use.10 The same finding emerged in our study. Among monogamous couples we queried where neither partner was sero-positive, only one woman negotiated fairly consistent use of condoms. She is older than her male lover; he seems intellectually impaired and dependent on her. "He's not that bad against it [using condoms]. He's still young. As long as I don't say no to having sex," she analyzes. She added, "I'm more the guy in the relationship."

Male Cooperation: Familiarity with Condoms and Age Factors

Experience may be a factor influencing whether couples will use condoms. "I've seen proposing [the use of] condoms lead to arguments. How to put it on, there has to be air in it, or no air in it," recalls one respondent. "We've had arguments," she admits. "Not about using it, but how to use it. I guess it's based on we really didn't know how."

"His friends that do use them, they can make foreplay with it [the condom]. [But] he went soft with the condom. Maybe that's why he didn't like it," observes one woman whose partner won't use condoms. Inexperienced users, in particular, may refuse to use condoms if they interfere with sustaining an erection.

A YES outreach supervisor generalizes that it is the two age extremes among men — the oldest clients and the youngest clients — who consider using condoms without much resistance.11 For the oldest males, condoms were the most popular form of birth control, and they observed a major epidemic during their lifetime. The vaccine for infantile paralysis (polio) was discovered in 1954.12

The youngest group of men have grown up during the widespread occurrence of herpes, AIDS, and other sexually transmitted diseases (STDs). An outreach supervisor who counsels homeless runaway youth reports that "one of the transition points for boys is getting a STD. Then they get scared, and start using condoms for a while. As long as they're on antibiotics, they use rubbers."

Additionally, sex is one of the few primal skills that people learn after infancy. (Perhaps this accounts for the myriad psychological complexities that sexual behavior entails). The novelist Marguerite Yourcenar observes:

Popular tradition has not been wrong in regarding love as a form of initiation. The first approach gives to the uninitiated the impression of a ritual, which is more or less frightening, and shockingly far removed from the functions of sleeping,
eating, and drinking; it appears matter for jest, shame, or even terror.13

The youngest group of males may feel less self-conscious about learning how to use condoms since they are just beginning their sexual lives. They may be willing to risk another awkward learning situation.

The "baby-boomers," the middle group of men, began their sexual activity with the Pill and intrauterine device as contraceptive choices. They represent a generation that had no contact with epidemics, and who witnessed dazzling triumphs of science (e.g. landing astronauts on the moon). "Men got spoiled:" ventured an administrator, "they didn't have to use condoms [to contraceptl, and they grew up knowing that a quick round of antibiotics could take care of venereal disease." One respondent reminisced about this time period: "Condoms, nobody [was] really using them. Most you could get was syphilis. Go get your penicillin, [and be] back on the street again. It wasn't a killer. The killer hadn't arrived."

Developmentally, the life experience of this middle group of men is that science can perform miraculous victories, and can find a cure for nearly anything. It is exasperatingly difficult to convince this group of men that the responsibility for controlling the AIDS epidemic lies with their individual behavior. "No!" we hear them protest. "AIDS is a problem for the experts."

Male Cooperation and Violence

Isolated cases of men becoming violent when their partners asked them to use condoms were reported in this study. Referring to the same man who passes out condoms to his friends, one woman describes her situation: "My man is a fighter. Last night he wanted to make love. I said, "Put on a condom." She continues, "It becomes a physical fight. I just give in."

"He knows that I know he has [unprotected] sex with other women. 'You don't even care, I tell him. The women, they don't care either. But we got a family. It ain't just us. We got kids.'

One 52-year old heroin user confessed, "Condoms? Child, I'm going to tell you the truth. Most all my life, I never did use them: you get a fight on [by] me. She weep, she always go for it [i.e. consents to unprotected sex]."

"When you're young, you're stupid. It's common sense if you got that. Just go on with the raw material [without a condom], it's not safe, it's not cool. You can save lives with a condom."

Intimacy

"Love doesn't protect. Condoms Do.'14

Whether they feel intimate with a partner affects respondents' willingness to use condoms. But the way in which intimacy affects behavior varies. The dominant pattern is that individuals do not use condoms with their primary partner. The most common justification for not using condoms is faithfulness. Offers of free condoms are likely to be dismissed with "We're in good shape. We're monogamous," or "I don't go out and mess around," or, "I've been with my lady awhile."

 Repeatedly the choice not to use condoms together is presented as an affirmation of trust and fidelity. "We don't even use bleach together," one woman told me proudly.

One outreach supervisor postulates, "People of color think that if you tell them to use condoms you're either accusing them of being 'nasty' (promiscuous or unclean), or you're saying they're unfaithful, or their partner is cheating on them." Worth states that one of the preexisting conditions that determine whether women can introduce condom use to their male partners depends is "the possibility that other sex partners can be acknowledged without seriously threatening the relationship."15 One counselor, who is a Latina herself, generalizes:

Latina women have an issue being an initiator. We don't even talk to our husbands about paying the bills, let alone negotiate condoms use. Women [Latina clients] will be very polite, take your condoms, and dump them in the trash on the way out. They don't want to have condoms seen in them house because it gets turned on them. Their partner will accuse them, "Hey, what are you doing that I have to be afraid of?"

Many clients do seem to regard the suggestion that they use a condom with their primary partners as violating the sanctity of their mutual commitment. Proposing to modify sexual behavior under these conditions is prickly. The outcome is that nearly all outreach staff agree, "Most of our couples don't use condoms."

"The more I care about someone, the harder it gets to use condoms," concede one homosexual male. He has cancer, and expects to test positive for HIV. "We'll be [sero-] positive together!" promised another gay male who asked his HIV positive lover to not use condoms. This man did seroconvert; he tested positive for the presence of HIV antibodies, and ultimately terminated his relationship with the man who infected him.

In contrast, intimacy can prompt a different response. An outreach worker who counsels homeless runaways recounts how a young woman who had always refused condoms in the past, surprised her by asking for some. "My boyfriend and I are getting along real good!" she announced happily. We're going to be together all week-end. Give me a bunch of condoms. We'll use them all. According to the outreach worker, the young woman's attitude was that unless her sex partner cared about her, she was not going to care about herself. "Maybe they got drunk and forgot to use the condoms," speculated the outreach worker, "but the intention was to use the condoms. She took about ten."

One man whose partner turns tricks said, he "got to thinking" about what could happen. He decided he and his partner would use condoms. Nonetheless, a distinction was still made. His partner "double-bags" (uses double condoms) with her tricks, but uses a single condom with him.

Intimacy and Bargaining

Bargaining often occurs when couples agree to use condoms. One woman explains, "When we don't use condoms, it's both our idea. Because there is a difference. Once a month [or] twice a month, we don't use condoms."
However, compromising can mean the opposite: agreeing to use condoms. "We use condoms more after we use drugs than when we're straight... We already took a chance using drugs. We better not take a chance with sex." The man who offered this insight injected drugs about twice a day. His partner is also a drug injector.

Intimacy and Anxiety

One man received a sero-negative test result while his wife was pregnant. The next day he panicked, "I've got it! I've got it!" he announced to his wife. He'd shared an uncleaned needle within 24 hours after getting his test result. He informed his wife that they would now start using condoms.

A variant of this "morning after" syndrome was seen to operate with other respondents. Next-day guilt over participating in a sex orgy has also impelled men to begin using condoms for a brief time.

Intimacy and Personalizing the Prevention Issue

"Hypothetically, is there anything that would persuade you to use condoms?" respondents were asked.

One woman gave an unexpected response. "If I was getting raped, I'd say PLEASE, PLEASE put on a rubber." Conceptualizing the transmission of HIV as a violent, loveless criminal act illustrates how sex partners may imaginatively dissociate themselves from the danger of HIV infection.

But typically, variations of the same answer to, "What would persuade you to use condoms?" were given. Among them:

If I knew my man was going out on me. If I knew he was going out on me. [But] both of us have been true to one another. I wouldn't hit the roof if he wanted to go out with someone else."

My husband is supposed to be monogamous. I do want to believe that he is. If it was affirmed to me that he is sexually active with somebody besides me, I could imagine him wearing condoms [with them]. But I don't have proof. Only guesses or fear. If I had proof, then I could picture myself saying, "This is what we have to do."

Often, respondents said that choosing to have sex with someone besides their regular partner would hypothetically persuade them to use a condom. For example:

If I was to break up with her [gestures to his wife], I'd use them.

Yeah, I can think of what would persuade me to use condoms. Me laying down with someone. Cause its going to be another dope fiend. [This woman's partner is in jail].

What would persuade me to use condoms? Everything I've learned. I'm female. I'm Latina. I'm an I.V. user.You ask questions? I ask questions, too.

But the prevailing sentiment, especially among women, seemed to be:

If I was [going] to date, I'd use them [condoms]. But not if it was a steady gruy.

A YES administrator theorizes, "intimacy equals protection and love. But condoms intrude on intimacy; they don't enhance it. In this case, intimacy backfires. The greatest problem we will have in this epidemic is with people who love one another."

Procreation

People who want to conceive children don't use condoms. According to one outreach worker, Catholicism instructs married women in the Latino community, "we shall have all the children that God gives us".'6 Condoms are viewed as contraceptives; using them defies religious teaching. It is difficult for Latinos to re-conceptualize condoms as devices that protect against HIV. A related outcome of this socialization may be the tendency to choose a single type of contraception exclusively. One Latina woman went off birth control pills prior to request-ing condoms. It made no sense to her to use what she perceived of as two types of contraceptives simultaneously. Her incentive to try condoms was her husband's upcoming release from jail. She expected him to "go crazy" at first, engaging in numerous unprotected sexual encounters.

An outreach supervisor reports:
Consistently, among homeless kids, the young women want to be pregnant. For instance, I have a 14-year-old female client. She's had two children already, and she is desperate to get pregnant. She gets pregnancy tests just about every week.

Whether options other than motherhood exist to define self-identity or self-esteem will affect women's introducing condom use, observes Worth.'7

Death Defiance

How respondents perceive risk, and characterize their behavior, can be mystifying. A female heroin user who works as a prostitute through a telephone service states earnestly, "My husband and I are not promiscuous." A female respondent says,

My husband is a former I.V. drug user. The previous women he lived with have both been prostitutes and I.V. drug users... Well, I never asked him to wear a condom because I really didn't have a fear that he had anything to infect me with.

Males' belief in their invincibility is sometimes expressed in ethnic terms. One Native American insisted that no one in his tribe has ever had or will ever have, AIDS. Asian men have made similar claims. Or, "I'm black. My body is strong. I can fight off that virus," is a variation of the "bulletproof attitude outreach workers report hearing frequently.

"I don't have to worry about AIDS because I don't have sex in San Francisco," explained one respondent. "I go to Oakland." He believes that geography protects him from HIV.

"[Ifl you don't have AIDS, I can look at you and tell you're clean." This is how a different respondent defends his decision to not use condoms.

For other respondents, it appears that there is romance in taking deadly risks. "I like taking chances," one man states simply. He neither cleans his needles nor uses condoms.

Teenagers express a type of "magical thinking".18 A CHOW supervisor based at a shelter for homeless run-away youth describes a female client who rejects using condoms. "She has a serious crack, speed and heroin habit. She's had hepatitis three times, her liver is enlarged. She couldn't be more at risk.

"I've broken every rule," is her attitude. "If I'm not infected now, I never will be."

"It does seem like a contradiction, I almost see her point," muses the supervisor. "I do wonder how they can be HIV negative when they've fucked or shared needles with everybody in the hotel."

"Our client group goes out with the purpose of getting fucked up, not just getting high," continues the supervisor.

We've got 14-year-olds that go to a club. They beat each other up there. A girl told me a story. She and a guy fought. Afterwards, he gave her the finger. She gave him the finger back. They fought more. "And then," the girl told me blissfully, "We kissed." "Doc Martins" are heavy boots that the kids wear. The same girl enthusiastically showed me her black-and-blue marks. Imprints of Doc Martins were all over her body.

How do you talk about safer sex," despaired the supervisor, "to someone who is proud of her bruises?" "Tell her bruises heal. AIDS is for keeps," recommended an administrator.

"What? yelled the supervisor. "And take away her status? Then she might tell me, "Maybe I'd better cut myself; that'll leave scars."

Referring to another case, the supervisor discloses, I have a new client, a black male 14-year-old. He's just declared himself gay and a drag queen. It's like he's started on a 10- point list of self-destructive activities for his new identity. The more drama, the
more he feels he's the star. I think his attitude is that if he gets AIDS he'll be a full-blown member of his new cohort."

Future Thinking

The lifestyle of many respondents results in their facing death in more immediate and dramatic ways than AIDS. Asked about her expectations for the future, one woman replied, `Truthfully speaking, five years from now I might be dead. I'm saying five years from now, but it may not even be that long."

Other respondents articulate middle-class fanta-sies for the future although the disjuncture from their present situation to their goal seems almost insurmount-able. Planning seems to be limited to 2-week segments between the 1st and the 15th when respondents receive their government checks. In this context, prevention messages for safe-guarding their future against the sexual transmission of HIV may have a limited impact.

Responsibility to Oneself and Others

One couple has made an educated decision not to use condoms. The man is sero-positive, but it should be noted that except for swollen glands and exhaustion, he is not symptomatic. They say they want to share the same fate.

"Why should we use condoms? We're going to die anyway," is the most common attitude among couples in which both partners are sero-positive. CHOWS and counselors stress to them the danger of reinfection and encourage them to stay alive long enough to see the development of a successful treatment.

The relentless message that poignantly comes through many of these narratives is that respondents are socially isolated. People are with one another, they're having sex with one another, but a sense of belonging is absent. On a local level there is very little with which people identify. The sense of community seems reduced to oneself and one's sex partner.

Unlike homosexuals, heterosexuals do not regard AIDS as a threat to the community. Among other elements, they lack the minority status and oppression that led to the solidarity of the homosexual community to confront AIDS. In 1987, an anthropologist predicted:

...Gays have a tremendous advantage. They've already confronted their sexuality. One of the problems I see with the spread of AIDS in the heterosexual community is [that] heterosexuals ...don't admit to their sexuality. I think heterosexuals are going to be very dangerous.19

Closing Remarks

Most couples in our study who engage in high risk behaviors do not use condoms with their primary sex partner. Overwhelmingly, it appears that whether condoms will be used in heterosexual relations is essentially a man's decision. It runs counter to the cultural arrangements of the groups we studied to expect that women will insist that their partners use condoms.

World-wide, the main route for the transmission of HIV is sexual.20 Barriers to HIV transmission that depend on women and are under women's control are not available. An editorial in the American Journal of Public Healths urges that research should emphasize HIV preventive methods women could use.21 We fervently agree.

Cherni Gillman, Ph.D., is with Narcotic and Drug Research, 11 Beach St., New York, N.Y 10025 and Harvey Feldman is with the Youth Environment Study, 1779 Haight St., San Francisco, Calif 94117.

Footnotes

1 Melillo, Mark. "AIDS Report: Pregnant Women and Newborns to Feel Greatest Impact of AIDS in the 1990s." Internal Medicine World Report 5, No. 12 (15-30 June 1990): 1.

2 Lambert, Bruce. "AIDS in Black Women Seen as Leading Killer." The New York Times. 11 July 1990. 83.

3 Worth, Dooley. 'Sexual Decision-Making and AIDS: Why Condom Promotion among Vulnerable Women is Likely to Fail." Studies in Family Planning 20, No. 6 (November/December 1990): 297-307.

4 Stein, Zena. "HIV Prevention: The Need for Methods Women Can Use." American Journal of Public Health 80 (1990): 460-462.

5 Newmeyer, John. MidCity Numbers. Bulletin. San Francisco, California. August 1989. 3.

6 Ibid.

7 Johnson, Dirk. "At Colleges, AIDS Alarms Muffle Older Dangers." The New York Times. 8 March 1990. Al2.

8 Worth, p. 301.

9 Plant, Martin, editor. AIDS, Prostitution, and Drugs. Tavist,ock: Routledge & Kegan Paul, 1990

10 Worth, p.297.

11 Penn, S., personal communication, February 1990.

12 Compton's Pictured Encyclopedia. Chicago, Illinois: F.E. Compton & Company, 1960. Volume 14. 487.

13 Yourcenar, Marguerite. Memoirs of Hadrian. New York: Farrar, Straus & Giroux, 1981. 13-14.

14 AIDS Education Program, State of California. "Condom Comebacks." Slide Chart. Los Angeles, California: Perrygraf

15 Worth, p. 297.

16 Gallardo, D., personal communication, February 1990.

17 Worth, p. 297.

18 Feldman, Douglas. "Anthropological Research on AID'S." In Comparative Perspectives on AIDS. Proceedings from the Hunter College Conference Perspectives on AIDS: A dialogue between Social Scientists and Health Professionals. Edited by Ida Susser and Claire Jagemann. 15 December 1987. 3.

19 Kreniske, John. "Anthropological Research in the Caribbean and Its Implications for the Study of AIDS." In Susser and Jagemann (editors). 28-29.

20 Stein, p. 460.

21 Ibid.