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A Little Thing Called Love: Condom Use in High-Risk

Primary Heterosexual Relationships
By A. Michelle
Corbett, Julia
Dickson-Gómez,
Helena Hilario and
Margaret R. Weeks
A. Michelle Corbett is
program coordinator,
and Julia DicksonGómez is associate
professor, both at
The Center for
AIDS Intervention
Research, Medical
College of Wisconsin,
Milwaukee. Helena
Hilario is research
assistant, and
Margaret R. Weeks
is executive director,
both at The Institute
for Community
Research, Hartford.

CONTEXT: Condoms are less likely to be used in primary relationships than in other relationship types. An
understanding of what women and men expect when entering into these relationships, as well as how they make
decisions about condom use and other prevention behaviors, is essential to efforts to curb the spread of HIV.
METHODS: Qualitative in-depth interviews were conducted with 25 high-risk heterosexual couples, including
HIV-serodiscordant couples, participating in a trial of the female condom in Hartford in 2004–2007. Data were coded
and analyzed in an iterative inductive and deductive process.
RESULTS: Participants described nonuse of condoms as a strategy to find and maintain a primary relationship,
establish trust and increase intimacy. Many had unprotected intercourse while recognizing their risk of HIV and
other STDs, placing their love for their partner and other emotional needs over concerns about their health. Several
couples reduced their STD risk by practicing negotiated safety (i.e., using condoms until their serostatus had been
determined) or similar strategies, including sharing sexual or drug use history, disclosing HIV test results and using
condoms until they decided that their relationship would be monogamous.
CONCLUSIONS: HIV prevention approaches must recognize the importance of love and the needs that primary
relationships satisfy if they are to be considered relevant by those at greatest risk. Negotiated safety and similar
strategies may be an important risk reduction tool for heterosexuals, particularly those in HIV-affected relationships,
but their potential effectiveness may vary.
Perspectives on Sexual and Reproductive Health, 2009, 41(4):218–224, doi: 10.1363/4121809

Rates of HIV infection are rapidly increasing among
women in the United States and worldwide.1,2 The majority of new infections are among women who contracted
the virus from their primary male sexual partners;3 the
predominance of this route of transmission reflects that
condom use is lower in primary relationships than in
casual or paying relationships.4–6 A variety of factors are
associated with couples’ use of condoms, including gender
inequity and differential power relations;7-9 occurrence of
intimate partner violence;10,11 levels of perceived risk12,13
and self-efficacy;14,15 and beliefs that condoms feel unnatural, reduce sexual pleasure and are a hindrance to
intimacy.16,17
Some studies have focused on women’s reluctance to use
condoms in primary relationships and have included
reproductive intentions9,18 or the use of hormonal and
other forms of contraception.12 Other research has focused
on the emotional and social needs that are fulfilled in committed relationships, and has found that condom use may
be inconsistent with relationship ideals of intimacy, trust
and fidelity.9,19 These explanations may be particularly relevant for inconsistent condom use by couples who know
that they are serodiscordant, but not for those in which
partners have the same HIV status.3,20 Further, most
research on the relationship between emotional needs,
romantic attachment and condom use has studied the
218

importance of primary relationships from the woman’s
perspective but has overlooked the man’s.
Public health policymakers and practitioners conceptualize sex in terms of disease and unwanted pregnancy, and
not in terms of love, intimacy and trust. This is particularly the case with regard to substance users, who typically
are described as having sex partners, rather than spouses
or lovers.21 Regardless of the population, HIV prevention
efforts have focused primarily on the individual, emphasizing risk reduction through safer sex, often neglecting
the context in which risky behavior occurs. However, safer
sex in the age of HIV and AIDS entails talking about condoms and acknowledging the possibility of disease. Such
discussion may not be conducive to a romantic, spontaneous, passion-filled encounter that might lead to love and a
long-term relationship. In contrast, some people use casual
or unprotected sex as a strategy to “catch love.”22 Among
heterosexuals, particularly young women, trust and love
are central in defining sexual involvements. Young women,
and sometimes men, often “trust to love,” in that they see
condom use as unnecessary with a regular partner or
within a relationship.16,23 Furthermore, young women
often view love and trust as prophylactic, and believe that
sex is safe because of its relationship with love.22
In the search for love and a meaningful relationship,
people may not always act rationally. For example, they
Perspectives on Sexual and Reproductive Health

December 2009 positively. High-risk individuals were defined as illicit drug users. RESULTS The majority of participants were nonwhite and poor. reproductive intentions. negotiated safety as a risk assessment and reduction strategy has been a focus of research.22. In addition to longitudinal surveys conducted with a cohort of more than 400 women. Written informed consent was obtained from each participant prior to STD screening and study enrollment. Specifically.24 Condoms and their use within a primary relationship. three couples were seroconcordant positive.31 its use by heterosexual couples has received little attention. 59. Men and women were always interviewed separately and were compensated $25 for each in-depth interview. If they responded Volume 41. such as first sexual experience with partner. All study protocols were reviewed and approved by The Institute for Community Research institutional review board prior to initiation of any research activities. Data were then coded for content using a coding scheme developed for the project. which comprised the following broad categories: first sexual experience with current partner. we explore reasons cited for condom use or nonuse. violence and substance use. relationship ideals. Study staff approached men and women found together in parks and on the street outside of social service organizations. and had low levels of educational attainment. and asked them if they were a couple. and knowledge of. it might encourage participants to have more sex (albeit protected sex) than they would otherwise have. the couple was excluded from participation in this component of the study and was referred to the local health department for treatment.32 In this article. We present findings from the baseline in-depth narrative interviews conducted with 25 couples.8.may base decisions about sex and condom use on implicit personality.ti software. sexual behavior. Because this approach proved difficult. men and women may follow one of several inaccurate AIDS prevention rules of thumb that support nonuse of condoms (e.24. staff told them about the study. Current relationship duration averaged five years (standard deviation. sexuality and pleasure. Interviews were first coded for demographic variables. Recruitment for the couples component of the study used two approaches. violence. range. every third woman participating in the larger cohort study was screened for eligibility and was asked if she would like to participate and would be able to bring in her male sexual partner.25 Also. then decide to discontinue condom use within their primary relationship and commit to monogamy or establish rules for condom use with outside partners. sexual negotiation and sexual practices.7 months.g..28–30 Negotiated safety refers to an explicit agreement between partners about sexual practices that takes into account the HIV status of both. can raise issues of distrust and accusations of infidelity. partners of injection-drug users. screened them for eligibility and scheduled them for an appointment to enroll at the study office. we examine condom use within the context of high-risk urban couples. sexual negotiation. explored current and past relationships. In a third level of analysis. and the other seven were serodiscordant. Eight couples were homeless at the time of their first interview. and researchers disagree as to whether heterosexuals are likely to employ it effectively. within primary partnerships. and the strategies used to reduce STD risk. we changed to direct recruitment of couples using targeted outreach. including both HIVseroconcordant and HIV-serodiscordant couples. attitudes toward and experiences with the female condom. the study included a couples component of qualitative and quantitative longitudinal interviews and a two-week trial of the female condom. Participants in the couples study provided a urine sample for screening for chlamydia and gonorrhea. individuals had to be 18 or older. To be eligible.* In-depth narrative interviews. once a relationship is established. and the majority had abused these drugs in the past. and text data were coded and analyzed through an iterative inductive and deductive process using Atlas. Initially. on whether a potential partner is from the streets or looks clean). exploring factors affecting highrisk men and women’s use of the female condom for STD prevention after barriers to awareness and accessibility have been removed. Number 4. If either partner reported current STD symptoms during the survey or tested positive with the urine screen.27 In recent years.26 Unprotected sex helps maintain the fantasy that one’s partner is faithful. sexual practices. Couples using this approach undergo mutual HIV testing. All qualitative interviews were transcribed verbatim. *This exclusion was based on the assumption that because the couples component included a two-week trial of the female condom and filling out sexual diaries. male condom use. members of the research team worked jointly to identify key themes and patterns of response and relationships among the variables of interest. For example. Nearly half currently used crack or injection drugs. STD risk and preventive practices. the importance of love was a recurrent theme and was related to many other codes.or characteristics-based risk theories (e. conducted at baseline and 10 months. “Known partners are safe partners” or “It’s too late to start using protection now”).. 219 . commercial sex workers. Six women and seven men reported that they were HIV-positive. live in the Hartford area and have had vaginal sex with this partner during the last 30 days.g. METHODS Our data were collected as part of a study conducted in Hartford in 2004–2007. While the frequent use of negotiated safety among homosexual men is well documented. general attitudes toward condoms. particularly an established relationship in which they may not have been used previously. and homeless or poor individuals. sexual and contraceptive decision making.

we didn’t use [a condom]. He says. or was not currently involved in another sexual relationship. in describing their ideal romantic partner. He said his was negative. HIV-negative 38-year-old) met Wilfredo while in methadone maintenance treatment. Amanda (a white. ‘How come you didn’t use any protection with me?’ You know. talked about having spent years searching for a soul mate and having found one in their current partner. they had been together for about three months. their nonuse of condoms supported the hope that this was not just a fling. Again. particularly a nonabusive one. … That is one thing I do believe. the first sexual encounter with their current partner was not just about sex but also about establishing trust. both women and men talked about “taking a chance on love. the importance of finding a life partner. Many women reported having unprotected sex despite some doubt about their partner’s monogamy. that’s how it was *All names have been changed. Love and Intimacy As they described the beginning of their current relationships and first sexual encounters. In these situations. Mine was negative. and I know you’ve been honest to me so far and I can trust you. they spent a year as friends. HIV-negative 44-year-old) had spent several years in an abusive relationship before she met Manuel.” Veronica echoed many other participants’ view that the use of condoms signifies a level of distrust. … We’re supposed to be together. it often Perspectives on Sexual and Reproductive Health . At the time of their baseline interviews. Carmen’s realization that Manuel might be her soul mate was somewhat complicated by the fact that he was HIV-positive. … [But] the chemistry. I was a little bit scared because I didn’t know much about AIDS or anything like that. Several participants. However. I guess nobody can honestly say 100% that they believe their mate is messing around or not. many participants believed that condoms are appropriate for casual and “sex-only” encounters but not necessarily for primary. who was involved in a relationship at the time.Condom Use in High-Risk Primary Heterosexual Relationships 1–240 months). and she had no way of confirming whether he had used condoms with his former partner. reported never using condoms. While they were physically attracted to each other. and she described both an immediate physical attraction and a deeper emotional bond stemming from hours of conversation about their experiences. He wasn’t just going to be this one person I was just going to mess around with and then … not see him. HIV-negative 41-year-old)* had known Juan for two weeks before they first had sex. Veronica (a Hispanic. And we didn’t even talk about it. I could not believe it. In addition. HIV-negative 38-year-old) further illustrated this point in her remarks: “We honestly believed that we wouldn’t ever have sex with anybody else again. Jennifer (a white. Rather. So … I was so proud of him that at least he was using rubbers with them and the reason he didn’t with me [was] because he trusted me. … [But] we both had had HIV tests. They met while in an inpatient detoxification program. Carmen and Manuel had been together about eight years and used condoms inconsistently. It’s like something that you have together. 220 with me and him. he was using protection. Veronica recalled that as their relationship evolved. They had been together about two months at the time they enrolled in the study.” Nonuse of condoms was a strategy employed to help establish a potentially serious. choosing to believe that he was faithful. In turn. as opposed to casual. the need for physical and emotional intimacy outweighed health concerns. relationship. having sex without a condom was used as evidence that a partner had been honest about his or her sexual past and disease status. but the day after. I was at least hoping that I was going to be with him [for a long time]. And I do know that he’s not messing around. Carmen (a Hispanic. No. and he was using protection [with her]. You understand what I mean?” For many participants. I ask him. However. during that time. she “didn’t want to have sex right away. but if he’s just dating someone like he was dating this girl just for sex. Explaining why they chose not to use condoms during their first sexual experience.” Doubt about a partner’s fidelity did not typically lead to confrontation or insistence on condom use.” Amanda’s desire to be in a long-term relationship and belief that Juan could be the one made it easier not to use condoms during their first sexual encounter. but rather a first experience with someone who was equally invested in fostering a meaningful primary relationship. The overwhelming majority of couples. she continued: “The first time … was so great. a soul mate. which is still true this day. in my heart I believe. and many couples reduce their STD risk through negotiated safety and similar strategies. she believed his assertion and took his nonuse of condoms with her as evidence of the seriousness of their relationship. Two main themes emerged from the in-depth interviews: Couples often feel that the love and intimacy needs that romantic relationships meet supersede health concerns.’ … He’s the type of guy that when he’s in love with a woman. serious relationships. So we just felt that in using [a condom]. ‘Because I trust you. well. They became friends and started dating after two years. outweighed her fears about health risks as she started a sexual relationship with him. because he had a girl before me. their feelings deepened.” and she was as nervous as a teenager when they finally did. I mean. However. including six of the 10 affected by HIV. it would be more of a blocker of our love. … Being sick or whatever can’t stop that from happening. Amanda stated: “I knew I was just going to be with him. Carmen explained: “I’ll be honest. Veronica knew that Wilfredo had been having sex with another woman as they started to get to know each other. he don’t like to use protection.

HIV-positive 37-year-old) had been with Lazaro for 20 years when she entered the study and had received an HIV diagnosis in 1992. … Then we started back again. … Well. Javier confirmed that he is willing to risk his life “for being happy. the emotional and other needs that are fulfilled by intimate relationships may supersede concerns for personal health and safety. and she accepted the perspective that it was “too late to start using condoms now”.resulted in continued unprotected sex. because I was hurt. Well. I love him and so what. and some couples reported never explicitly discussing their risk or condom use.35 Finally. ‘That’s my man. the emotional and other needs that are fulfilled by intimate relationships may supersede concerns for personal health and safety. That’s it. they have some type of disease. because I feel so comfortable and I feel great and I’m living this life. but I wouldn’t have left him because he had AIDS. they may be willing to die for love.” Ana’s story also suggests additional themes. it took us a while before we had sexual relations. … Half of [the people there] are sick or something. you know. she had to decide whether to leave him. flesh and flesh. related: “When we first met. So she had taken her [HIV test]. … She wanted to protect herself. The couple had been together for three years at their first interview. leaving them unwilling to risk losing what they have. you know? Right now I’m enjoying it. as Manuel’s comments suggest. HIV-negative 44-year-old) commented: “What’s the use of using [condoms]? I mean.27 In addition to reduced physical pleasure. Javier and Karla’s story is another example of how love sometimes supersedes concern about risk. reinforced misperceptions about AIDS or people with AIDS and helped to maintain the fantasy of the ideal—namely. agreed to be monogamous and engaged in unprotected sex. Javier (a Hispanic 29-year-old) responded: “That’s a good question. and whatever happens. it is not clear whether she did so because she felt that getting infected and dying with him would be better than being left alone after he died. or stay with him and not use condoms. you know? His meat against my meat. Ana also displays a certain level of fatalism. [Once I found out. When asked what prevents him from taking precautions against infection. José and Linda. Why? I think your body fluids or whatever is intimacy. they had HIV tests. as illustrated by Manuel and Carmen. you know?” Manuel’s narrative also raises the issue of “condom fatigue. I go with the flow like I always do.] … I didn’t want the sex or nothing for a while. … I think a condom means that you really don’t want contact. Because the love was already there. Stories related by participants in HIV-affected relationships illustrate that for many people. or frustration with the prospect of having the pleasure of sex reduced at every encounter. In extreme cases. once Ana had come to terms with the fact that the man she loved was HIVpositive. HIV-positive 33-yearold) explained that he had been using condoms for so many years.” He said that Carmen sometimes feels the same way. … And the feeling. “so sometimes we have sex without a condom. Never used condoms because I said. you know? So I think maybe he was afraid. it may even result in inconsistent condom use despite the very real risk of HIV transmission. because she assumed that he had already infected her. Whatever time God wants [to give me and then] he’ll take me. I shouldn’t Volume 41. you 221 .” Balancing the desire and need for physical intimacy and protecting oneself or one’s partner was particularly difficult for serodiscordant couples. We’ll die together. it happens.34 combined with the desire and need for physical intimacy. just that … I would have been more protective. After assessing their risks and intentions for the relationship. we met in a program. or for a combination of reasons. may prove overwhelming at times. Number 4. you know. I’m having the best time right now. decided to use protection at the beginning of their relationship because of their drug use histories. or a belief that her destiny is not in her own hands. Although she chose to stay with Lazaro and not use condoms. you know? Like I said. If I love him. Assessing and Minimizing Risk Several couples described assessing their HIV risk as they decided whether to use condoms. I don’t want to change this for nothing. I love him and everything. December 2009 even use condoms with him.24 as a conscious expression of her love for him (which has been suggested as a major reason for nonuse of condoms in serodiscordant relationships20). Yet. she explained: “[Knowing that Lazaro was infected] wouldn’t have changed nothing. that a partner was faithful. This. … It’s only for hookers or somebody that you don’t … want to feel their immediate skin against yours. She had received an HIV diagnosis in 2005. several participants associated using condoms with reduced intimacy. Martha (a black.’ That’s how I felt. safe and founded on true love. Sometime before learning that she had HIV. and we used condoms at first ’cause. … It’s like something that we want to share. Feelings of betrayal at not only Lazaro’s dishonesty regarding his HIV status but his disregard for her health are evident.” which is frequently discussed in research on sexual behavior among men who have sex with men33 and may also operate in heterosexual—particularly serodiscordant—partnerships. stay with him and use condoms.’ But I didn’t know [about reinfection] at the time. and Javier continued to test HIV-negative. she told me to use [condoms].” For many people. in turn. and we didn’t use condoms. but sometimes he just “[wants] to feel. a Hispanic 32-year-old who was HIV-negative. and had felt betrayed and hurt because he had not told her himself. although the thoroughness with which they did so varied considerably. you know. both physical and emotional. Manuel (a Hispanic. Ana (a Hispanic.” When the interviewer probed this response. which supported the belief that the relationship was monogamous. ‘Damn. José. who had been together for four and a half years. Condom fatigue. I don’t know. she had found out from Lazaro’s sister that he was HIV-positive.

Condom Use in High-Risk Primary Heterosexual Relationships The challenge … is to … promote the importance of protection as complementary to the desire for love and intimacy. 222 know? … She made the decision. This evidence went beyond whether someone “looked healthy” or seemed like “that kind of person. upon the realization that they both had hepatitis C infection and had had negative HIV tests before they met. romantic relationships. can help couples increase trust and intimacy within their relationship. they had agreed that since they both had been tested for HIV and other STDs and they were monogamous. Roberta’s risk assessment relied on characteristics-based theories and Lionel’s claim that he used to carry condoms. José explained that after a while. or acknowledged a real risk of contracting HIV (as in serodiscordant couples). their use of these strategies apparently was not consistent throughout the relationship. they then decided to continue to use condoms while waiting to see if they were still HIV-negative and if their relationship was becoming a committed and monogamous one that included a relatively high level of discussion and negotiation. Several couples described using some form of risk assessment and reduction at the beginning of their relationship. she took his word that he had tested negative for HIV prior to their meeting. these factors seem to have very little effect on the desire or ability to use or insist on condom use within their relationship. couples may engage in more or less effective or conscientious assessments of their risk. Most participants were well aware of the risks they were taking. as well as the fear of loss due to death.” For Roberta. many participants ignored or minimized their risk. then. Given the importance of establishing and maintaining committed. Amanda. and many abused drugs. they tended to be in long-term. based on open and honest communication. stemmed from their desire to establish and maintain a loving and meaningful relationship. a black. In fact. illustrates this point in her comments about her partner. and involved very little discussion. While it is clear that several couples consciously engaged in negotiated safety or other strategies to assess or reduce their risk at the beginning of the relationship. nevertheless. Because couples in our study saw condom use as inconsistent with establishing and maintaining a committed. intimate partner violence and self-efficacy play a role in condom use generally. DISCUSSION While factors such as substance use.” he said. Serodiscordant and concordant-positive partnerships are faced with particular challenges in terms of intimacy and the barrier to it that condoms can present. to express love for one’s partner. These examples reveal three approaches to assessing risk with potentially very different levels of success in actually minimizing risk. Not using condoms. they had no reason to use condoms. at whatever cost. Similarly.” Asked at what point he and Linda had decided not to use any protection. because he always had condoms on him. the fact that Lionel carried condoms meant that he used condoms with other partners and therefore was safe. and I agreed with it ’cause we just met not too long ago. Risk reduction programs should help highrisk individuals understand that ongoing risk assessment. they may have had a greater need for security. who had never used condoms with Juan. acceptance and reciprocated love than is typical in heterosexual populations at lower risk for HIV infection. “We shouldn’t be sick. A few participants described using characteristics-based theories and other “evidence” in determining whether their partners were safe for unprotected sex. Lionel: “I really couldn’t tell you [how I knew that he didn’t have a disease]. risk assessment and reduction strategies such as negotiated safety must be reconceptualized and communicated to high-risk heterosexuals as a way of increasing intimacy and strengthening relationships. including risk to their health. this information came out over the course of many hours of conversation during which they and their partners discussed their pasts. Our finding that many couples were attempting to assess risk even though negotiated safety has not been widely promoted in the United States among heterosexuals suggests that this may be a more Perspectives on Sexual and Reproductive Health . and to be with that person and fully share his or her experiences. Jennifer had decided not to use condoms with her boyfriend. we can see that negotiated safety may be viewed as a continuum of levels of risk assessment and potential responses to risk. Study participants were overwhelmingly marginalized socially and economically. The challenge for researchers and practitioners is to develop interventions that address these concerns and promote the importance of protection as complementary to the desire for love and intimacy. Furthermore. they should explain that periodic testing may be viewed as a way of expressing love and maintaining trust within the relationship.” Roberta. HIV-negative 44-year-old. as when one partner was living with HIV or infidelity was suspected. they used other strategies—some more thoroughly than others—to assess and reduce their risk. Because of their marginalized and potentially stigmatized status. Alberto. but still chose not to use condoms consistently. Similarly. among these 25 couples. Entangled with the desire and need for physical pleasure are the desire and need to experience physical and emotional intimacy. This was the case even when considerable risk existed.” In comparing José and Linda with other couples. but not consistently throughout the relationship. “unless one of us went out there and fooled around and got sick. Amanda’s and Jennifer’s rested on the fact that both they and their partners had hepatitis C. José and Linda acknowledged that they had participated in high-risk behaviors before entering drug treatment. primary relationship. Finally. but finding their “soul mate”—a partner who would share and help them navigate through their difficult lives—and achieving a sense of “normalcy” were higher priorities. committed relationships. decided to engage in unprotected sex once she knew that they both had hepatitis C. … He must have been using condoms.

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