A Critique on Abstinence-Only Sexual Education –Stephanie Horton

Introduction:
The federal government has been supporting abstinence programs since 1981 when the Adolescent Family Life Act was implemented, but since 1996, there have been major expansions in federal support for abstinence programming and a shift to funding programs that teach only abstinence and restrict other information (1). In fact, federal funding for abstinence-only programs has increased from $60 million in 1998 to $168 million in 2005 (1).
Abstinence, as defined by policy makers, is not often clearly defined. In behavioral terms, abstinence is defined as “postponing sex” or “never had vaginal sex,” or refraining from further sexual intercourse if sexually experienced. Other sexual behaviors may or may not be considered within the definition of “abstinence,” including touching, kissing, oral sex, mutual masturbation or anal sex (1). Abstinence, according to government policies and local programs, is often described in ethical terms, using phrases such as “chaste” or “virgin” and framing abstinence as a positive attitude or commitment. A study by Goodson et al. found that abstinence-only educators in Texas and the youth in abstinence-only programs defined abstinence in moral terms, such as “making a commitment,” and “being responsible” (2). Overall, the term is often confusing and loaded with insinuation, which adds to the controversy it bares in abstinence-only sexual education programs.
While many schools in the United States provide sexual education consisting of both education about abstinence as well as other forms of birth control and sexually transmitted infection (STI) prevention, a number of curriculums in the U.S. continue to employ “abstinence-only” sexual education. Under the Welfare Reform Act Title 5 Section 115, abstinence-only sexual education must teach that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, STI, and other associated health problems, and no other form of sexual education is permitted (1). In Corpus Christi, Texas, the Communities In Schools (CIS) program implements abstinence-only programs that target the prevention of teenage pregnancy and premarital sexual activities by using three components including case management, curriculum, and parental involvement (3). The curriculum, called Choosing the Best, and its educational materials taught to adolescents 12-18 years old are consistent with Title 5 Section 115 Federal Guideline in that it teaches abstinence only. This program serves the following school districts in Texas: Corpus Christi Independent School District, Flour Bluff Independent School District, Tuloso-Midway Independent School District, Calallen Independent School District, West Oso Independent School District, Gregory-Portland Independent School District and Sinton Independent School District (3). Students enrolled in schools in these districts will receive the abstinence-only sexual education, which does not include education about contraceptive use and does not provide guidelines on how to practice safe sex.
This abstinence-only sexual education program is flawed in three major ways. First, abstinence is not 100% effective in preventing pregnancy or STIs as many teens fail in remaining abstinent. Secondly, the current federal approach focusing on abstinence-only raises serious ethical and human rights concerns. Finally, the implications of abstinence-only programs on the gay, lesbian, bisexual, transgender (GLBTQ) population may have adverse and potentially fatal outcomes. This paper aims to critique the abstinence-only sexual education public health initiative and will provide an alternative strategy for a sexual education curriculum for adolescents aged 12-18 years old.

Abstinence is not 100% Effective
It is not only misleading, but also potentially harmful to imply that abstinence from sexual intercourse is fully protective against pregnancy and sexually transmitted infection. This concept confuses theoretical effectiveness with actual practice. In other words, abstinence is not in fact 100% effective, because those who take a vow of abstinence often fail. In fact, most Americans initiate sexual intercourse during their adolescent years, the mean age for females being 17.4 and for males 17.7 (4.). Moreover, some STIs may be spread via other forms of sexual activity, such as kissing or manual or oral stimulation (1). The most useful data in understanding the efficacy of abstinence come from the National Longitudinal Survey of Youth (Add Health), which examines virginity pledgers and their adherence to abstinence (5-6). This data suggests that many teens who intend to remain abstinent, fail to do so, and that when abstainers do initiate intercourse, many fail to protect themselves with contraception (5-6). The study conducted a 6 year follow up during which the authors found that the prevalence of STIs was similar among those who took the abstinence pledge and those who did not (6). Therefore, pledging abstinence is not necessarily a 100% effective measure, and in fact, those who do not receive information about contraception but are educated on abstinence-only are actually put at increased risk.
In 2006, the Academy of Pediatrics released a position statement on sexual education. This statement concludes that adolescents are constantly exposed to sexual messages in the media, including social networking sites, television, movies, magazines and internet sites. The paper explains that American children and teenagers spend more than 7 hours per day with a variety of different media that contains sexual messages (7). According to the authors, the most recent studies on adolescent sexual behavior and media influences have resulted in four main conclusions: 1) Listening to sexually degrading lyrics is associated with earlier sexual intercourse, 2) Black female teenagers’ exposure to rap music videos or X-rated movies is associated with the likelihood of multiple sexual partners or testing positive for an STI, 3.) Teenagers whose parents control their TV-viewing habits are less sexually experienced, and 4.) Exposure to sexual content in the media is a significant factor in the intention to have sex (7). All adolescents are exposed to this type of media. Therefore, those who are receiving abstinence-only education are put at a disadvantage, because as the Add Health data suggested, teens rarely remain abstinent and if they did not previously receive education about other forms of contraception, they are less likely to protect themselves during sexual activity.

Abstinence-only Education is Unethical
It is a paradoxical observation that while abstinence education is often based on morality, the current federal approach on abstinence-only education is ethically flawed. The U.N. Committee on the Rights of the Child has emphasized that children’s right to access adequate sexual health information is essential to securing their rights to health and information (8). Therefore, since the federal approach to abstinence-only education prevents sexual education about contraceptive use as well as gay sexual education, it can be concluded that abstinence-only programs violate basic human rights. This type of sexual education does not provide the full spectrum of information that adolescents, and all people, have the right to learn. If a student in one of the Texas school districts under the abstinence-only curriculum desires knowledge about contraceptive use or safe sex practices, that student has to seek educational material out of the school. Not only will these children feel moral conflictions but often these adolescents will be unaware of the resources available as they are only being taught one form of sexual behavior: 100% abstinence from sex.
Governments have an obligation to provide accurate information to their citizens, and by omitting an important part of sexual education, the abstinence-only program outlined by the federal government is putting thousands of students at risk. If the adolescent is not equipped with the proper tools to protect himself/herself, the teachers of that adolescent have perpetrated a serious ethical injustice.
An international treaty called The International Covenant on Economic, Social and Cultural Rights specifically outlines the obligation of the government to provide its citizens with the information necessary for the “prevention, treatment, and control of epidemic…diseases,” such as HIV/AIDS (9). In additional to this international call for ethics, the United National Guidelines on HIV/AIDS and Human rights also provides guidance, “ensure that children and adolescents have adequate access to confidential sexual and reproductive health services, including HIV/AIDS information, counseling, testing, and prevention measures such as condoms” (10). The abstinence-only education programs are directly going against this guidance by not educating students about condom use and other preventative measures.

Gay Lesbian Bisexual Transgender (GLBTQ) Population and Abstinence-Only Education

Abstinence-only sex education has the potential to have profound negative effects on adolescents of the GLBTQ population. As many as 1 in 10 adolescents struggle with sexual identity and abstinence-only classes are likely to ignore the needs of this population, as homosexuality is often stigmatized and viewed as deviant behavior in this curriculum (1, 11). Therefore, it is important to consider the effects of homophobia, which include health problems such as suicide, feelings of isolation and loneliness, HIV infection, substance abuse, and violence among GLBTQ youth (1). It is not far-fetched to conclude that abstinence-only problems may indirectly cause these feelings and/or conditions in the GLBTQ adolescent student.
Under the federal requirement of abstinence-only education, emphasis must be placed on heterosexual marriage only and is defined as the only appropriate context for a sexual relationship. Lifelong abstinence as an implied alternative, therefore, holds this group of youth to an unrealistic standard which is extremely contrasting to that of their heterosexual peers. Not only does it put “moral” stress on these students, but it may teach them that their feelings toward sex are ethically wrong or even “grotesque,” and in some cases, sacrilegious.
Those youth who live in the school districts in Texas where this abstinence-only program is being implemented are put at risk for these potentially fatal consequences which result from the nature of abstinence-only sexual education.

A Flawed Social Behavioral Model

The Theory of Planned Behavior (TPB) behavioral model is a good tool to use when understanding the flaws of the abstinence-only education programs. This model explores the relationship between behavior and beliefs, attitudes, and intentions. The most important determinant of behavior according to this model is behavioral intention, which is influenced by a person’s attitude toward a behavior and by beliefs about whether individuals who are important to that person approve or disapprove of the behavior. This model also includes perceived behavioral control, meaning it assumes the person believes he/she has control over his/her behavior (12). The concept of perceived behavioral control is similar to the concept of self-efficacy. It describes an individual’s perception of his/her ability to perform the behavior and his/her control over the opportunities, resources, and skills necessary to perform that behavior. This is believed to be a critical aspect of this behavioral model (13).
This theory can be applied to the goals of abstinence-only programs. These programs assume that adolescents will remain abstinent because 1.) Their attitudes and beliefs can be molded so that they feel abstinence is the only accepted form of sexual behavior, and 2.) They care deeply about the approval of their peers, parents, and teachers. The abstinence-only sexual education guidelines also assume that if adolescents receive education about abstinence-only, they can be influenced to perceive strong control over their own behavior, which has been shown to have an influential effect.
This theory, as well as this curriculum plan, has limitations. First, the theory does not allow for decisions to change based on context and environment. In other words, students who receive abstinence-only sexual education may be influenced one way or another depending on their environment, such as sexual messages in popular media as The Academy of Pediatrics pointed out (7). Without acknowledging this fact, abstinence-only seems like it would work. However, realistically, these students are not likely to remain abstinent, and if they do not receive education about safe sex, they are more likely to suffer the consequences of unprotected sex compared to their counterparts who receive complete sexual education (4).
TPB assumes that behavioral intention will lead to the behavior, but it does not consider the time between the behavior intention and the actual behavior (12). In other words, the abstinence-only program does not consider the time between the adolescent’s intention to behave a certain way and the actual way the adolescent behaves. As seen in the Add Health data, often adolescents who take the virginity pledge fail to remain abstinent (5). This is a major limitation in this type of sexual education and can be seen clearly when TPB is applied.
This type of sexual education assumes that behavior is rational and static, a major limitation that is also seen in TPB. Adolescents are constantly changing, and their values are constantly molding. In their state of growth, behavior and attitude are anything but rational and static. Emotions are often elevated in these individuals, and so we cannot assume that when faced with the decision to remain abstinent, these adolescents will behave in the way they have been taught. This theory and plan simply ignore the adolescent’s feelings of rebellion and curiosity, thereby putting them at serious health risk. If these students learn nothing but abstinence as a form of sexual protection, they are not equipped with all the materials to keep them safe from the consequences of risky sexual behavior.

Proposal for National Comprehensive Sexual Education

A safer, more reasonable and realistic approach to sexual education is a standardized comprehensive sexual education curriculum implemented nationally. This curriculum will include the following topics: abstinence, puberty and the changes that occur, contraceptive use, where/how to obtain contraceptives, instruction on condom use, access to condoms, information on “how babies are made,” sexually transmitted infections, abortion, masturbation, homosexuality and sexual identity, oral sex, and a complete guide to resources available to help students practice safe sex.
Comprehensive sexual education should be available to all adolescents age 12 to 18 in all schools. The curriculum should cover each year these adolescents are in school and should remain current in its information and delivery. These programs should provide clear definitions of abstinence free of propaganda. This type of sexual education will make all sexual health information available to adolescents through the school system and will not discriminate based on sexual identity.
Public polls have expressed a need for a national comprehensive sexual education curriculum. These polls suggest that while abstinence is certainly a favorable behavior goal for adolescents, there is strong national support for education about contraception and for access to contraception for sexually active adolescents (14-15). More specifically, data from these polls found that 90% of parents believe it is very or somewhat important that sex education be taught in school, and only 15% of parents wanted an abstinence-only form of sexual education. 99% of parents polled believed that it was appropriate to provide high school and middle school students with broad information on sexual issues, including STI, the physiology of pregnancy and birth, having intercourse at an older age, making responsible sexual choices based on individual values, how to use and where to get contraceptives, abortion, masturbation, homosexuality, oral sex, and 71% of parents believe that teens should be able to obtain birth control pills from clinics and doctors without parental permission (15).
Over 800,000 adolescents become pregnant each year, and 80% of these pregnancies are unintended and/or end in abortion (16). In addition to these compelling statistics, an estimated 18.9 million STIs occur each year in the United States, and almost half of these cases occur in adolescents and young adults under the age of 25 (17). Long term consequences of STIs can include infertility, tubal pregnancy, fetal and infant demise, chronic pelvic pain, and cervical cancer (17).
The statistics and polls mentioned are compelling to say the least. They not only demonstrate a need for a national curriculum of comprehensive sexual education, but also a widespread acceptance of sexual education among parents. As stated, only 15% of American parents want abstinence-only sexual education (15). That means that 85% of American parents are supportive of sexual education that includes a comprehensive overview of all available safe sex practices. Therefore, a national standardized program would be well received and would prevent teens from engaging in risky sexual behaviors.
Two recent systematic reviews examined the evidence supporting abstinence-only programs and comprehensive sexual education programs. Both of these reviews demonstrated that comprehensive sexuality education effectively promoted abstinence as well as other protective behaviors among adolescents. Both reviews found no scientific evidence that abstinence-only programs demonstrate greater efficacy in delaying initiation of sexual intercourse. Therefore, a comprehensive sexual education program would not sacrifice any benefits that are believed to exist in abstinence-only programs.
Although federal abstinence-only education funding language requires teaching that sexual activity outside of marriage is likely to have harmful psychological and physical effects, there is no scientific evidence suggesting that consensual sex between adolescents is harmful. There are no reports in the scientific literature that address whether the initiation of adolescent sexual behavior itself has an adverse impact on mental health (1). Therefore, it is not unreasonable to question the government’s focus on abstinence-only education programs. This emphasis on abstinence-only is not just ineffective, but it may also be harmful to other public health efforts such as family planning programs and HIV prevention efforts. A comprehensive approach to sexual education would actually enhance these programs and would not discriminate against GLBTQ youth the way abstinence-only programs do.
Not only will national comprehensive sexual education provide teens with the necessary tools to prevent unwanted pregnancies and sexually transmitted diseases, but it will also allow parents to trust that their children are receiving complete educations through the school system. U.S. adolescents will have the knowledge they need to practice safe sex, and through the scientific literature discussed in this paper, it can be concluded that comprehensive approaches to sexual education do not lead to earlier initiation of sexual behavior. In fact, they have been shown to delay sexual behavior similar to or even more so than abstinence-only programs.
It is strongly suggested that Title 5 Section 515 of the Welfare Act be amended to recommend comprehensive sexual education to all U.S. adolescents through the education system. By doing this, we will protect our adolescents from harmful sexual consequences. A comprehensive sexual education is more ethical, more effective, and less discriminatory than an abstinence-only program, and in this free country where we strive to fulfill the rights and needs of our citizens, it is the only appropriate form of sexual education for our nation’s children and adolescents.

References

1. Santelli J, Ott M, Lyon M, Rogers J, Summers D, Schleifer R. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 2006; 38;72-81.

2. Goodson P, Suther S, Pruitt B, Wilson K. Defining abstinence: views of directors, instructors, and participants in abstinence-only until marriage programs in Texas. J Sch Health 2003;73(3):91-96

3. Communities in Schools Website. http://www.ciscc.org/abstinence.cfm Accessed on December 4, 2010

4. Abma J. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002. Vital Health Statistics 2004;24:1-48.

5. Bearman PS, Bruckner H. Promising the future: virginity pledges and first intercourse. American Journal of Sociology 2001;106:859-912

6. Bruckner H, Bearman PS. After the Promise: the STD consequences of adolescent virginity pledges. Journal of Adolescent Health 2005;36:271-278

7. Strasburger V. Sexuality, Contraception, and the Media. Pediatrics 2010;126;576-582.

8. Committee on the Rights of the Child. General Comment No. 3 (2003a) HIV/AIDS and the rights of the child, 32nd Sess. (2003), para. 13. 2003.

9. International Covenant on Economic, Social and Cultural Rights. Adopted December 16, 1966, entered into force January 3, 1976, GA Res. 2200A (XXI), 21 UN GAOR, 21st Sess., Supp. No. 16, at 49, UN Doc. A/6316 (1966)

10. United Nations. Report of the International Conference on Population and Development (Cairo, 5-13 September 1994). New York; 1994. Report No.: A/Conf.171/13.

11. Kemper ME. Toward a Sexually Health America: Abstinence-Only Until Marriage Programs that Try to Keep Our Youth ‘Scared Chaste’. New York, NY: Sexuality Information & Education Council of the United States, 2001.

12. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. National Cancer Institute Website 2005;2:9-21. http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf Accessed on December 6, 2010.

13. Refugee Well Being Website. Health Promotion and Disease Prevention: An introductory Article. http://www.refugeewellbeing.samhsa.gov/PDF/Toolkit/7_Health_Promotion_Article.pdf Accessed on December 6, 2010.

14. Albert B. American Opinion on Teen Pregnancy and Related Issues. Washington DC: National Campaign to Prevent Teen Pregnancy 2004.

15. Dailard C. Sex education: politicians, parents, teachers, and teens. Issues Brief 2001;2:1-4.

16. Henshaw SK. U.S. Teenager Pregnancy Statistics with Comparative Disease Surveillance, 2003. Atlanta, GA: U.S. Department of Health and Human Services, 2004.

17. Weinstock H, Berman S, Cates W. Sexually Transmitted Diseases among American Youth. Perspective on Sex and Repoductive Health. 2004;36:6-10.

The ineffectiveness of current approaches on educating the severely mentally ill about sexual health and a proposal for change – Ivy Zang

Few formal sexual health programs exist for the mentally ill. While much research has been done to demonstrate the need for such programs, little research has been done to determine the proper way to construct and deliver a program. The approaches documented in literature rely upon traditional public health models, which erroneously assume the individual to be rational and impervious to outside forces. The studied interventions also fail to discuss the unique needs of the mentally ill. An ecological approach incorporating predictable irrationality is necessary to minimize risky sexual behaviors among mentally ill adults.
Evidence of need for intervention.
Severe and persistent mentally ill (SPMI) adults experience major functional disabilities and undergo recurrent relapses requiring periodic stabilization and hospitalization (1). Since 1955, SPMI individuals have been deinstitutionalized from state hospitals into the community. This change in treatment has yielded a need to develop and improve sexual education programs for the mentally ill (2).
Historically, the SPMI were viewed as asexual, a view that stemmed from forced sterilizations and institutionalization. However, in a recent study of 400 SPMI adult patients of a outpatient clinic, 94% reported engaging in sexual intercourse (3). In addition to being sexually active, mentally ill adults often engage in high risk-sexual behaviors. Ten percent of the sexually active SPMI individuals in the study reported exchanging sex for housing, drugs, or money. More than half reported not using a condom in any of their last five sexual acts (3). Women with SPMI have more lifetime sexual partners than women without mental illness (4). Schizophrenic women have the same number of pregnancies as women without mental illness, but a greater percentage of them are unplanned and unwanted. Despite not wanting to become pregnant, sexually active women with schizophrenia often do not use birth control and lack basic knowledge of contraception (5). In a study of males with SPMI, nearly one-third reported engaging in sexual intercourse with a partner that they knew for less than twenty-four hours (6). HIV rates in the mentally ill are estimated between 5% and 7%, in contrast to 0.6% in the rest of the population, and 30% to 60% of SPMI individuals are at elevated risk for contracting HIV (7).
Critique 1.
The public health community fails to address the issue of high risk sexual behaviors among the mentally ill as sexual education programs targeting this population are few and far between. The Royal College of Nurses describes the sexual health care and education of people with SPMI as “inconsistent and inadequate” (8). This may be due to concerns about confidentiality, competency, and treatment responsibility (9). Only 38% of psychiatric hospitals have policies regarding sex relations. Only 58% of those policies include statements about contraception or sex education (10). Many facilities are opposed to offering sexual education programs, anticipating a resulting increase in sexually inappropriate behaviors on the unit, even though literature shows that most clients can tolerate exposure to sexually charged material without de-compensation or acting-out sexually (11).
This resistance to sexual health education stems from a “lack of knowledge about sexuality, conservative attitudes, and anxiety when discussing sexual issues” among mental health providers (12). In a study of British mental health home care nurses, the nurses felt that 41% of their patients would be comfortable discussing sexual issues with them, while only 50% of nurses felt comfortable discussing sexual issues with their patients (13). Although most mental health professionals believe that their patients will present the subject if necessary, most SPMI individual are not prepared to defy social and professional norms to bring up sexual health issues (14). Most adults with SPMI want to be informed about the social and environmental effects of illness on their sexuality and they want their providers to initiate this discussion (12).
Critique 2.
Where formal sexual education programs do exist, they are based on the framework of traditional public health models, most notably the Health Belief Model (HBM) and the Theory of Planned Behavior (TBP), which also predominate sex education programs for the non-mentally ill. Most sexual education programs investigated in the literature attempt to educate while promoting behavioral change. Most of the studies use small group interventions that rely on cognitive factors, behavioral skill factors, and external consequences in an attempt to change behaviors (15). Although some of the studies show reductions in risk behaviors, these effects are time-limited and repetition is necessary to maintain even short-term behavioral gains. Only a few studies examine actual behavioral change at the end of the intervention and even fewer follow-up with patients to determine the long term gains. As participation in the studies was voluntary, the examined samples were comprised of highly-motivated volunteers (7).
A study of 35 group home residents involved three l-hour educational sessions, focusing on AIDS, risk behaviors, risk reduction, and condom use. Pre and post-intervention questionnaires assessed knowledge and did not reveal a change (16).
A three-session invention at an outpatient mental health clinic in Boston focused on sexual education, AIDS information, and condom use training. The study showed increased knowledge amongst participants, but did not assess behavioral change (17).
A study of 52 participants of a community support program in Milwaukee involved four 90-minute sessions focusing on HIV education, sexual assertiveness, negotiation skills, condom use, risk reduction and problem-solving. At a one-month follow-up, the rates of unprotected intercourse declined by 50% and the proportion of condom protected intercourse occasions increased from 18% to 53%. However, long-term changes were not assessed (18).
In a study of patients at a mental illness community center, six biweekly sessions focused on the transmission of STDs, HIV/AIDs myths, perceptions of the threat of infection, risky behaviors proposed by partners, screening sexual partners, and barrier contraception. Participants’ HIV information scores increased from 66% of questions correct during pre-intervention to 75% correct at post-intervention and remained at 75% correct at 1 month follow up. However, there was no significant change in participants’ attitudes towards condom use and the participants appraised their risk of infection as relatively low both before and after the intervention (19).
A study of 189 SPMI individuals at an outpatient clinic involved a 7-session small group intervention that focused on risk reduction, condom use, handling personal triggers for risky sexual situations, problem-solving, personalized plans to implement personal behavior change, communication, negotiation, and assertiveness. Men who attended the intervention only showed improvement in knowledge, while female participants changed their attitudes toward sexual behavior and increased their percentage of condom-protected vaginal intercourse occasions from 20% to 47%. This gain amongst females decreased substantially at the 12-month follow-up (20).
In a study of 97 chronically psychotic men with co-existing substance disorders living in New York City homeless shelters, subjects were randomly assigned to either a brief AIDS education or a 15-session risk reduction intervention incorporating condom use, communication skills, and risk management of situations known to be encountered by homeless men, including casual sexual contacts, sexual behavior while intoxicated, and same-sex contacts. Outcome analyses revealed greater reductions in unprotected intercourse and increases in condom use among participants in the intervention than the control group. Behavior changes remained observable through a 15-month follow-up, but weakened over time (21). Although this 15-session program proved effective, programs of this length are often not economically and logistically feasible.
In addition to the limited ability of the interventions noted above to elicit substantial behavior change, the health promotion literature has suggested many limitations to the traditional health care models. Many studies testing HBM and TPB-based interventions yield results that are inconsistent with the models’ constructs (22). Both models focus on individual decisions and do not address the multi-level ecological causes of behavior addressed in the next section of this paper. The basic assumption behind the models is that the individual has the ability to make rational and cognitive-based decisions; however, this inability is inherent in the diagnosis of mental illness (23). These models assume that health behaviors are simply based on attitudes and beliefs, failing to address the many other factors that influence health decisions (24). Psychosis and delusional thought amongst the SPMI may alter perception of real world events, but the mentally ill do not live in a vacuum. Even subtle changes in context and environment can drastically influence an individual’s health behavior decisions. For instance, the increase in motivation to have sex produced by sexual arousal is proven to decrease the relative importance of protecting oneself from unwanted pregnancy and STDs (25). An individual who has strong intentions to always wear condoms when engaging in intercourse with a new partner may spontaneously engage in unprotected sex if he is sexually aroused and condoms are not readily available. In addition, an individual with bipolar disorder may typically lead a monogamous lifestyle, but may engage in unprotected sexual encounters with multiple partners during an acute manic episode. By assuming that behavior is static, the models do not take into account the spontaneous actions that characterize most of human behavior (24). Lastly, these models assume that people value health highly (24). Health is a value that has a specific place in each individual’s value system, therefore the relative importance of health and its degree of influence on behavior varies among persons (26). Based on a randomly distributed survey of core values and preventative health behaviors, researchers determined happiness, pleasure, salvation, and a comfortable life to be the strongest core values for individuals who do not engage in preventative health behaviors. Those who do not engage health preventative behaviors rank health as a lesser core value than world piece and inner harmony (27).
Despite the obvious flaws with the models, health care practitioners continue to apply them to interventions. As these traditional health models serve as the basis for nursing and public health education, mental health professionals often rely upon these models when planning interventions (28).
Critique 3.
Sexual health interventions present in the current literature are based on generic cognitive-behavioral intervention models and have not been “specifically tailored to the special needs, risk situational circumstances, and change barriers likely to be encountered by the severely mentally ill” (7). The mentally ill face unique issues inherent in their diagnoses, their treatment, and the social and political consequences of their disease. The SPMI are unable to weigh costs against benefits when multiple ecological forces are in fact driving their decisions.
Although SPMI individuals are less sexually active than the rest of the population, those who are sexually active often engage in higher risk sexual behaviors. These high risk behaviors may be derived from poor interpersonal functioning, impaired psychosocial development, cognitive deficits, poor judgment, impaired decision making, labile mood, and impulsiveness leading to high levels of sexual vulnerability. Information processing deficits related to severe mental illness may inhibit people with SPMI from benefiting from preventive interventions that are based on traditional behavioral change principles (29). Hyper-sexuality, aggression, deep dependency needs, efforts to compensate for feelings of inferiority, response to auditory hallucinations, loneliness, and boredom may also be motivating factors for high risk sexual behaviors (30). The SPMI often have difficulty forming and sustaining stable sexual and social relationships. Sexual encounters amongst the mentally ill usually occur within casual relationships and some are “characterized by naiveté, abuse, and exploitation” (7).
Individuals with SPMI often have low levels of sexual health information, lack basic vocabulary of sexual terms, and have many misconceptions about sexual anatomy and physiology (5). In a focus group of rural women with SPMI, many held false beliefs, knew little about contraception and general women’s health, and did not receive regular gynecologic examinations (31).
The SPMI tend to be unemployed, impoverished, and overrepresented among the homeless, the incarcerated, and other disadvantaged groups at higher risk for STDs (9). Due to socioeconomic disadvantages, the mentally ill may also have tenuous and transient living arrangements and are often disproportionately concentrated in inner-city neighborhoods with higher rates of drug use, STDs, and HIV infections (7). Fifty percent of the mentally ill suffer from a dual diagnosis of chemical dependency which has synergistic implications for increased high risk sexual practices. Patterns of exchanging sex for drugs, lodging, and basic survival needs are not uncommon (7). Many SPMI individuals lack resources to purchase condoms and oral contraceptives (9).
The general population often stigmatizes the SPMI, attributing mental illness to sin or lack of character or willpower (33). The media transmits multiple misconceptions about the mentally ill, including that they are homicidal maniacs or rebellious free spirits. This stigmatization decreases their self-esteem and hinders their ability to make friends and sustain social relationships, which may augment risky sexual behaviors (34). The SPMI lack political power and strong advocates, inhibiting change on community and governmental levels (9). Although organizations like the National Alliance of Mental Illness (NAMI) serve as powerful community resources, their legislative lobbying efforts are limited due to insufficient monetary funds (35).
Intervention.
Since multiple causes contribute to high risk sexual behaviors among individuals with SPMI, including the illness itself, an ecological approach is essential. Enhanced prevention strategies must extend beyond individually focused cognitive-behavioral interventions and address the broader psychosocial context in which risk behaviors occur (36). As behavior is affected by multiple levels of influence, interventions must be planned at an intrapersonal, organizational, community, and public policy levels (37).
The ecological model encourages educational programs, support groups, and counseling at the intrapersonal level (37). However, at the intrapersonal level, the ecological model does support the use of the traditional health promotion models determined earlier in this paper to be incapable of changing complex human behavior. This is an evident limitation of the ecological model; however, this level of the ecological model can be adapted with theories of predictable irrationality, most notably framing and ownership. Successful public health programs utilize “potentially effective combinations of established theory (38).
At the intrapersonal level, a sexual health program should be provided to patients during inpatient hospitalizations as most SPMI individuals have multiple hospitalizations over a lifetime, allowing for a broad target audience and multiple reinforcement sessions. On the inpatient units, staff nurses or mental health workers should lead a sexual health group multiple times during the week for the patients nearing discharge, as the ability to process information resumes when the acute phase of illness subsides (11). Groups should be informal with the ultimate goal of empowering the patients, not reprimanding or frightening them (39). To account for the cognitive impairment of many SPMI individuals, the group must start with a concrete discussion of sexuality, including reproductive anatomy and physiology, the transmission of disease, and contraception (15). During the educational session, instead of framing AIDS and STDs as severe and detrimental and trying to evoke fear as would be encouraged by the HBM, educators should reframe them as diseases preventable and controllable through communication with partners and avoidance of sexual risk (15).
Practicing condom use is a vital component of this intervention (11). When marketing condoms to male patients, the educators should, in addition to advertising the safe-sex benefits, reframe the action as a gain or a positive experience by reinforcing that condoms extend sexual performance and postpone ejaculation. By presenting the message as sex-positive and making condoms fun and erotic, the educator can reframe an individual’s perception, easing the process of seceding ownership of the high risk sexual behavior and increasing the likelihood of condoms use. When educating female patients on how to deal with male partners who refuse to wear condoms, the educator should describe the female condom as a tool capable of empowering women. The educator should reinforce the idea that the female condom is just as effective as the male condom, taking away the man’s power in the sexual relationship. When the female condom is reframed as a gain—a symbol of empowerment—safer sexual practices may emerge. Patients should be instructed to carry condoms with them at all times in the community, as people often underestimate their likelihood of having sex when in non-aroused states and will not make an effort to find condoms in an aroused state (25). Masturbation should also be discussed as a safe alternative to sexual intercourse. Traditionally, psychiatric units have had strict “no masturbation” policies and punish patients caught masturbating. This brings shame and embarrassment to the act. Masturbation should be reframed as a gain: a safe outlet for channeling normal sexual drives when done privately (30).
Additionally at the intrapersonal level, psychiatric facilities should employ women’s health nurse practitioners to counsel female patients of childbearing age about contraceptive options before discharge as SPMI women often have difficulties using community facilities for family planning (41). Mental health facilities are also more informed than family planning clinics as to how mental illness affects informed consent for family planning (42). On the day prior to discharge, the nurse practitioner should discuss the available contraceptive options. Injectable hormonal contraception, depo-provera, is the most appropriate contraceptive choice for use in this population. It lasts for three months and does not have significant clinical interactions with any anti-psychotic medications (5). Similar to the framing of the female condom, the nurse practitioner should frame the injectable contraceptive as a gain. It can be framed in terms of freedom and power: freedom from pill taking and a newfound power in the sexual relationship. The majority of patients who receive family planning counseling and are started on contraceptives in psychiatric hospitals continue contraception use after discharge and follow up with providers (5). As the SPMI often have difficulty utilizing community resources for contraception, have insufficient funds to purchase contraception, and underestimate their need to have contraception readily available, nurses should give condoms to both male and female patients at every discharge along with the discharge medication list.
Psychiatric facilities can utilize changes in organizational characteristics to support the behavioral changes of its patients. This includes changes in institutional commitment, policy and procedures, actions of staff members, and learning opportunities (37). As long as mental health professionals do not feel comfortable discussing sexual issues with their patients, the diffusion of comprehensive sexual health programs across psychiatric facilities will be unsuccessful (13), (14). In order to increase the comfort of mental health professionals, psychiatric facilities should provide continuing education programs that encourage providers to introspectively examine their attitudes and sensitivities to various aspects of sexuality in order to become more comfortable sexual issues (42), (43).
For program diffusion to be successful and behavioral change among SPMI individuals to be possible, the policies and corporate culture of psychiatric facilities must change. Policies must not rely on the personal judgment of staff, but should be sensible, sensitive, and validate the sexual rights of the mentally ill. Formal guidelines for sexual education, birth control, and capacity to consent must be devised (44). Organizational attitudes towards sexual practices must change along with new policies; staff members must not allow personal biases, fears, moral beliefs, and stereotypical beliefs to obstruct the implementation of new policies (45).
Community level interventions use existing social networks as mediating structures to influence community awareness (37). Depression and Bipolar Support Alliance (DBSA) is the leading patient-directed national organization for individuals with SPMI and has a strong social network (46). Through a system of peer-run support groups, DBSA educates SPMI individuals on the impact and management of mental illness. The organization has been a success, as 86% of its members remain compliant with their psychiatric medications (46). This existing social network can be used to increase sexual knowledge amongst the mentally ill and encourage members in engage in protective health behaviors. As DBSA relies on peer-to-peer communication, the sexual health message delivered would be one of considerate concern from a friend, instead of a provider’s paternalistic educational message. DBSA creates a community of trust, reciprocal support, and positive self identity where healthy behavioral changes can occur (47). Peer-mediated sexual health interventions have proven to effectively reduce risky sexual behaviors in other high-risk populations and may serve as an effective tool in eliciting behavioral change amongst the mentally ill .
Regulatory policies are essential in protecting the health of the community (37).
Local departments of mental health (DMH) should develop policies to control many of the external factors that lead to impulsive sexual behaviors amongst the mentally ill. Local DMHs should increase their funding of intensive case management services, which have proven to positively affect functional level and quality of life, while preventing exacerbation of illness (48). With an increase of funding, more case managers could be hired and individual case managers could spend more time with their clients ensuring medication compliance, temperance, and stable living situations to decrease likelihood of risky sexual practices. Case managers can work with the local Social Security offices to appropriately budget their clients’ finances and prevent the exchange of sex for lodging and food. DMH should allocate increased funds for supportive housing. Supportive housing gives SPMI individuals that are particularly prone to sexual exploitation or risky sexual practices a unique opportunity to learn about and to practice safer sexual activities in a supportive context (49). DMH should expand substance abuse services for the mentally ill as substance use is the strongest correlate of high risk sexual practices in this population (50).
Defense of Intervention 1.
The ecological model is an appropriate basis for the development of a sexual health intervention for the mentally ill as it encompasses the multiple physical and social factors that influence the healthfulness of a situation and the well being of its participants. Based on the model, efforts to promote health should emphasize the advantages of multilevel interventions that combine behavioral and environmental components, like facilitating psycho-educational group interventions while changing the professional culture of psychiatric units (51). The ecological model focuses on population-level prevention and includes individual level interventions aimed at persons with certain risk factors, interventions mediated through important organizational channels, and public policy interventions that redirect societal counter forces (52). The proposed intervention operates on all of those levels. Effective interventions create therapeutic micro-environments that facilitate and reinforce desired health behaviors, instead “arm[ing] patients with behavioral control strategies and then send[ing] them off into society to maintain their treatment gains, leaving them at the mercy of a social system that encourages, rewards, and profits from high risk behaviors” (52). This is done by beginning the intervention in the hospital with groups and reproductive counseling and continuing the intervention in the community with case management and supportive living services. Extensive research has been done using the ecological model as a framework for understanding behaviors and despite the fact that current evidence supports multi-level interventions, only a relative few number of studies involving the ecological model as a framework for intervention are published in the health promotion literature (53), (54). Many published papers discuss successful interventions that utilize the ecological model, but do not test the intervention in a formal study (55), (56). Despite this dearth of research, a multi-level intervention will yield greater benefit to SPMI individuals than a sole intrapersonal level intervention.
Defense of Intervention 2.
Frames are an effective way of promoting protective sexual behaviors at the intrapersonal level, as health care promoters can manipulate frames to alter the judgments and opinions of the targeted population. A frame is a way of packaging and positioning an issue to convey a certain meaning. By packaging an issue in a more desirable way, health care promoters can change attitudes towards health behaviors and the likelihood of behavioral change (57). A meta-analysis of framing experiments in relation to health promotion proved framing to be a successful tool for interventions that involving safer sex (58). People are sensitive to whether an intervention is framed in terms of its associated costs (loss frame) or in terms of its associated benefits (gain frame), even when the two frames describe the same situation (59). Gain frame interventions are more persuasive than fear-inducing frames when it comes to implementing preventative behaviors, like condom use (60), (61). Threat or fear appeals advocated by traditional health models are ineffective in sexual health interventions as many people fear STDs or HIV without feeling that they are personally vulnerable and will downplay their own personal risk in comparison to risks of others (62).
Messages that are framed in unexpected ways or do not match participants’ experiences or concerns can be more effective as they lead to greater message processing (63). Instead of presenting a message of sexually transmitted disease and health effects, the proposed intervention delivers an unexpected sex positive message of freedom and empowerment. By changing the definition of the problem, it is thus possible to change the response. Although health is a core value for some, successful public health interventions must utilize frames that appeal to the same compelling core values being tapped into by the opposition (57). In a state of arousal, sexual pleasure is a much more compelling core value than health. By reframing condom use as a way to improve sexual activity, instead of a way to prevent disease, a more compelling core value is utilized.
Defense of Intervention 3.
As individuals quickly come to own their health behaviors, behavioral change is dependent upon their ability to give those behaviors up. When a health promoter is able to offer the individual a new behavior coupled with a compelling core value, behavioral change may be possible. Psychological ownership is the state in which individuals feel that a target of ownership is theirs. A target of ownership may be an object or a non-physical entity, such as ideas, words, or behaviors. The cognitive state of ownership is tied with emotional and physical sensations, including the rise of pleasure, efficacy, and self-identity. This leads to an intimate relationship between self and possessions; the entity may become part of the extended self (64). People tend to place a larger value on an entity when it is in their possession and resist to part with their possessions as they allow people to keep to the status quo. Over time, individuals come to own their health behaviors, thus their health behaviors become an extended part of themselves and are difficult to give up (65). As duration of ownership increases, the owned behavior increases in value (66). Despite the unattractiveness of risky sexual behaviors, owners still see parting with them as a loss (65). As people are “more reluctant to give up an attainment than they are eager to acquire it,” they must be persuaded with something that they value even more (66). As discussed earlier, pleasure has shown to be the most valuable of possessions for those who do not engage in preventative health behaviors, so for a person to give up risky practices, he or she must be offered pleasure in return (27). For men to give up sex without a condom, they must be given the pleasure of improved sexual performance. For women to give up passivity in sexual interactions, they must be given pleasure of empowerment.
Conclusion.
“Sexual activity among the [mentally ill] is a reality and one with which we must deal and not put our heads in the sand” (10). The mentally ill are sexually active and do engage in high risk sexual activities due to lack of education, the complexities of mental illness, and social and behavioral factors. Due to attitudes and beliefs of health care professionals, the sexual practices of the mentally ill have long been unaddressed. High-risk sexual activities are a reality that traditional models of health promotion cannot change. An ecological approach along with the principles of framing and ownership could serve as an effective way of dealing with sexual activity amongst this vulnerable population.
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Social Marketing and HIV Stigma: The Need of Community Help with Marginalized Populations – Nicolas Karr

In 2008, 33.4 million people had a positive HIV status (1). Through out the year, 2.7 million new infections joined the tally and 2 million left because of AIDS-related deaths (1). The infection devastates low-resource populations. Prevention programs intervene to help these populations and provide the resources that could change the tide of infection. Unfortunately, while HIV/AIDS prevention programs provide the tools to fight infection, the populations do not necessarily change their behaviors. Content-rich interventions fall short when the target community does not use the resources.
In a summary analysis and critique of 21 interventions to reduce HIV/AIDS stigma, Brown, Trujillo, and Macintyre stated that HIV/AIDS stigma “undermines public health efforts to combat the epidemic” (2). They found that stigma affects the magnitude of reactions to epidemics and causes violence against infected people (2). Populations affected by stigma might fear societal attitudes and could deny their risk of infection. This denial could lead to inaction and ignoring risk factors; inaction could manifest as not using condoms, not testing for HIV, and not disclosing HIV status (2). Stigma can trigger actions to avoid a loss of a job, health benefits, or social ostracism (2). These actions on the part of the stigmatized could cause harm to themselves and the surrounding population. Acting in fear, marginalized populations experiencing HIV/AIDS stigma could endanger their relationship networks.
Stigma has prevailed throughout generations as an impediment to public health. When confronting disease, stigma causes negative views and reduces access to care. Stigma embeds itself within a population and breeds a culture of fear. In order to reduce infections in high-risk populations, interventions need to address stigma. In a meta-analysis of twenty-four studies, occurring between 2000 and 2007, of people living with HIV/AIDS in North America, Logie and Gadalla found that marginalized populations experienced higher stigma levels (3). Specifically, the researchers found stigma highly associated with low social support, poor physical health, poor mental health, lower income, and younger age (3). Consequently, according to Herek and Capitanio, who looked at behaviors towards people living with HIV/AIDS, stigma causes reduced access to care due to discrimination through violence and exclusion (4).
Marginalized populations endure the most stigma and these misunderstandings lead to low resources, poor funding, and inconsistent interventions and treatments. In order to help these populations the current interventions need to make changes. This paper focuses on three specific sub-populations at high-risk for HIV/AIDS and stigma: young black men, female substance abusers, and young men who have sex with men (MSM). The first section presents critiques on interventions targeted at each group and the second section provides ideas for improvements upon the current interventions. To stop the spread of HIV/AIDS, health interventions need to reach the high-risk, marginalized populations; interventions need to mitigate stigma to facilitate proper care.
Young Black Men: Bearing the Brunt of New Infections
According to the Centers for Disease Control and Prevention (CDC), African-Americans make-up 13% of the U.S. population, but account for 50% of all new HIV/AIDS cases, demonstrating a highly prevalent, yet underserved population (5). Along with high prevalence among the entire population, African-American men continue to acquire more infections than their female counterparts (5). HIV/AIDS prevention programs tend to show effectiveness in controlled settings, but the transfer to the real world has less than promising results.
When developing improvements for a current intervention to target young black men, O’Donnell et al. found that interventions have too many requirements and attrition sets in(6). This issue arises specifically with stigmatized populations who choose to avoid over exposure in HIV/AIDS programs. Dworkin, Pinto, Hunter, Rapkin, & Remien found that research tested the efficacy of prevention programs, but failed to design programs acceptable, affordable, sustainable, and adaptable to the population (7). HIV/AIDS has greatly affected young black men, but interventions have failed to address this issue. In order to reach the population O’Donnell et al. stressed the importance of tailoring the intervention for population penetration (6). The prevention programs fail to address barriers to care; HIVS/AIDS stigma limits accessibility to care and the interventions fail to reach the high-risk population.
O’Donnell et al. noted that a significant level of HIV/AIDS stigma develops from internalized and externalized homophobia (6). This stigma leads young black men to test late or avoid testing at all (6). O’Donnell et al. found that African-American females would seek medical care while young black males, more commonly, self-treat (6). This could explain why interventions fail to reach young black males, due to the medical services involved with HIV/AIDS testing. In addition, issues of stigma related to medical services inhibit access to care. Stigma of medical services among the population interacts with HIV/AIDS stigma and makes seeking care significantly less likely.
In order to overcome these obstacles, interventions need to address these issues of avoiding care. If evaluations of these prevention programs only focus on the efficacy in controlled settings, they fail to deal with issues of adaptability. The population at risk avoids medical services and HIV/AIDS care because of stigma. Until the interventions acknowledge this stigma surrounding the access to care, the programs cannot effectively reach those at high risk for infection.
HIV/AIDS interventions have many flaws, but simple changes in approach can lead to greater success. Evaluations of prevention programs need to address the dynamics within each high-risk population. Without adjustments to target different contexts, interventions cannot reach the populations. As stipulated, population penetration remains an important factor in all HIV/AIDS interventions (6); interventions must change to understand their population or fail in trying to reach them.
Female Substance Abusers: Inequality and Instability
HIV infection might come directly from sharing needles, but injecting and non-injecting drug use has developed as a risk factor for risky sexual behavior, a risk factor for HIV/AIDS. Among female substance abusers, risks for violence and HIV increase. Due to gender-specific inequality and violence, female substance abusers need interventions tailored to their issues.
Interventions of the past failed to address the gender-based issues of substance abusers. Wechsberg found, through a survey of past and present HIV/AIDS interventions for women, that past interventions did not account for low status in the culture and community, low education levels, and high rates of unemployment among female substance abusers (8). These factors significantly stigmatized the population. The interventions never reached the people because they could not access medical services. Beyond low access to health care caused by these factors, the high unemployment rates led the women to sell sex (8). The factors that increased stigma also increased the likelihood of acquiring HIV/AIDS.
With the increased stigma surrounding female substance abusers, the difficulty in reaching them increases. Wechsberg noted that failed interventions did not provide knowledge and personal enhancement training specifically targeted to changing behaviors (8). These behavior specific interventions could change behaviors when issues such as substance abuse, violence, and sexual risk arise (8). Culturally specific interventions targeted at females could improve the success of the programs. Unfortunately, the failed interventions did not acknowledge cultural specificity. The women find themselves without any power to act. The interventions fail to reach women who cannot make the decisions themselves or fear losing social support.
Interventions have low compliance to condom use because the programs ignored community context. In the case of sex worker interventions, Evans and Lambert, through an ethnographical study of HIV/AIDS community interventions, found that their noncompliance stemmed from lack of control over their work and social conditions (9). If prevention programs cannot change the dynamics within high-risk populations, distributing condoms makes no difference.
Evans and Lambert also observed that government policy and bureaucrats often disrupt interventions (9). Interventions unable to adapt to changing political tides must confront possible failure; police raids due to changing political temperaments could easily ruin months or years of community-building (9). Prevention programs must adjust to the changing political, cultural atmosphere in order to succeed.
The dependence the women have on the men controlling their lives continues to impede interventions. Failure to address gender inequality means more unsuccessful prevention programs. In order to aid female substance abusers, interventions need to provide ways to increase access to care. The women need to have feelings of safety and support if they choose to seek medical services. Without stability, predominant stigma and fear prevents access to care.
Young MSM: New Generations Facing Decade Old Problem
Stigma has been an impediment to care for all people living with HIV/AIDS. Among men though, internalized and externalized homophobia has led to fear of negative social consequences (10, 11). Valdiserri noted in his review of HIV/AIDS stigma literature that internalized homophobia led to lower self-esteem and consequently, a reduced sense of self-protection (10). This lack of self-protection leads to higher risk sexual behaviors and increased susceptibility to infection (10). These factors impede public health interventions that provide tools for safer sex, but ignore the inaction by participants.
The stigma surrounding young MSM and HIV/AIDS interact and result in negative self-feelings. According to Valdiserri, young MSM experiencing self-doubt seek validation through multiple partners (10). The environments where these encounters occur also facilitate alcohol and drug use and reduced inhibitions to practicing unsafe sex (9). Interventions fail to address young MSM dealing with negative self-feelings. Prevention programs do not work if the participants assimilate information, but make different choices in the heat of the moment.
Dowshen, Binns, and Garofalo studied the effects of HIV/AIDS stigma on four psychosocial measures among MSM. The measurements included depression, self-esteem, loneliness, and social support (11). They found some correlations between perceived stigma level and psychosocial measures, but due to a small sample size, could not declare significance (11). Among their study participants though, they found a correlation between perceived levels of stigma and discovery of a positive HIV status; both of these measures highest at the beginning and reducing with time (11).
Current interventions targeted at young MSM fail to change behaviors because they do not acknowledge how MSM incorporate stigma into their decisions (10). From sexuality to gender identity to HIV/AIDS, these young men deal with multiple levels of stigma (10). Until current interventions address how MSM deal with all levels of stigma, the ability to change behaviors significantly drops.
Prevention programs fail when they ignore the needs of the population. Many programs plan interventions based on best practice protocol. In the case of people living with HIV/AIDS, the programs focus on distributing prevention tools and education. The ethnographical research of Evans and Lambert found that different dynamics influence the decisions individuals make (9). These dynamics include context, practice, agency, and power (9). The researchers found that intervention evaluations review content and the relationship to the results (9). This traditional critique leads evaluations to base success on effectiveness of distributing project resources; grading the efficacy of interventions based on the number of condoms distributed or the prevention classes taught does not demonstrate the true intervention results.
Many problems dealing with population dynamics develop from transferring intervention models from one context to another. Evans and Lambert found that evaluations of efficacy for HIV/AIDS interventions lead to best practice protocols that ignore the context and dynamics of populations (9). Best practice guidelines fail to account for distinct circumstances of marginalized populations (9).

A New Design: Ideas for Change in HIV/AIDS Interventions
Stigma involves many different issues and they affect all facets of an intervention. However, interventions that deal with stigma can change the behaviors of high-risk populations. Valdiserri states that HIV/AIDS interventions need to empower people about health issues, mobilize communities to solve the health problem, develop policies and plans in support of individual and community health, and conduct research to find innovative solutions to health problems (10). By accomplishing these health services public health can mitigate the effects of stigma and effectively reach populations (10).
Behavioral theory remains an important part of affecting change among HIV/AIDS populations. Interventions that focused only on distributing resources to combat infection need to adjust for population-level behavioral dynamics. In a review of the AIDS Community Demonstration Projects, Yzer, Fishbein, and Hennessy found that behavioral theory plays an important role in designing HIV interventions; theory identifies thoughts and feelings that can determine behaviors (12). The researchers also determined that evaluations of interventions need to measure effects of behavior change associated with the variables the intervention modified (12); evaluations should look at how the intervention changes behaviors based on the targeted variables. This way the evaluation determines how the methods of intervention truly affected the population (12).
In their ethnographic study of community HIV/AIDS interventions, Evans and Lambert found that success developed from peer education, community mobilization, and structural interventions (9). These key points emphasize the importance of involving the target community in the intervention. Community involvement ensures individual empowerment and this leads to behavior changes. Brown, Trujillo, and Macintyre note that many of the successful interventions in developing countries utilized community-based approaches opposed to the individual level approaches employed in the U.S. (2). They speculated that the use of community-based approaches reflects an understanding that confronting stigma involves both collective and individual level action (2).
With these factors in mind, new HIV/AIDS interventions should utilize social marketing campaigns within high-risk communities to find opinion leaders and start programs for peer education, community involvement in promoting prevention techniques, and individual enhancement to mitigate HIV/AIDS stigma. An important focal point involves finding respected community leaders to lessen the fear of stigma. With proper influential leaders among the intervention, the programs can more effectively reach the target population. In the following sections, this paper focuses on specific techniques for intervening with young black men, female substance abusers, and young MSM.
Lessening the Burden of Young Black Men
In developing a new HIV intervention for young black men, O’Donnell et al. found that successful interventions must overcome barriers to disseminating information (6). The researchers also stated that the failure of medical services remains the inability to link young black men with needed medical services (6). Available resources do not translate to effective interventions.
O’Donnell et al. stresses the importance of a community review of program components before implementation of the intervention (6). This step makes sure the community understands the intervention approach and, more importantly, the design fits with community dynamics. The next step in a successful intervention includes social marketing. O’Donnell et al. used the community meetings to identify potential spokespersons that have influence (6). Along with recognizing leaders in the community, the discussions identified people young black men would listen too. The discussions determined peers had the greatest impact (6). Utilizing opinion leaders helped get young black men to seek medical services, but the next step involves reducing the requirements of the screening test. If the men find the screening test invasive, time-consuming, or overly demanding they might avoid testing (6). O’Donnell et al. noted the value of using context-pertinent learning models. The intervention utilized computer-based modules that the men found interesting and engaging. The learning module incorporated videos, games, and an overarching storyline that kept the interest of participants (6). Lastly, O’Donnell et al. stressed the importance of developing individual risk reduction plans. This allotted for population dynamics and allowed the men to voice their concerns (6).
Overall, the intervention proposed by O’Donnell et al. focuses on the effects of social marketing. Without the social marketing element, the men would never reach the screening test, learning module, or individual risk reduction plan. Most importantly, the social marketing approach involved the community. The community discussed each approach and component and aided in the successful implementation of the program.
Providing Stability and Equal Footing for Female Substance Abusers
In situations where a person living with HIV/AIDS has dependency issues, interventions fail to change behaviors. This problem stems from a persons’ inability to give up control, but interventions focus on their unwillingness to change. Resources do not aid those who need stability to utilize prevention methods. HIV/AIDS interventions focusing on female substance abusers need to incorporate personal enhancement programs into their prevention methods.
Commercial sex work, violence, and substance abuse usually intersect and complicate the issue of HIV/AIDS infections. Wechsberg found that interventions incorporating knowledge enhancement and hands-on skills training strategies could change behaviors in this population (8). The intervention needs to focus on empowering the woman to make assertive decisions.
Sex facilitates a main conduit for infection and improved condom use could come from enhanced negotiation skills (8). The women of this marginalized population tend to deal with inequality issues. This inequality leads to contexts with high risk of infection. Wechsberg notes that the ability to empower and enhance negotiation skills increases the likelihood of assertiveness with sex partners (8). The disparate contexts these women live in causes dependency and lack of power. In order for prevention resources to find use, the women need a feeling of stability. Effective enhancement and empowerment interventions could overcome the treatment barriers.
Utilizing community support in these situations could prove difficult. If the women do not have a network connecting them, peer influence might have little effect. With the right approach, communities could develop for these women. Sometimes, the health workers need to think creatively to piece together a network or community. If possible, this social support could improve the chances of behavior change after empowerment and enhancement training strategies.
A New Solution for Young MSM
The stigma surrounding MSM develops from both HIV/AIDS and sexuality. The issues intertwine and result in added fear of negative social consequences. In order to address MSM, interventions need to mitigate the stigma surrounding both HIV/AIDS and sexuality. Valdiserri noted that young MSM might avoid clinicians because of fear of judgment (9). If public health officials expect at-risk men to screen for HIV, they must account for worries of social ostracism. Brown, Trujillo, and Macintyre state that information, counseling, coping skills acquisition, and contact demonstrated effectiveness in interventions (2). The researchers also found that different approaches to coping skills acquisition occurred in several interventions and each showed effectiveness in the specific population (2). This point demonstrates the importance of tailoring the intervention to the community. The prevention program must work with the community to reach the target population.
Brown, Trujillo, and Macintyre present a different concept for interventions: contact. This method involves combating stigma through inducing empathy for people living with HIV/AIDS (2). They saw positive results associated with the contact method, but overall the method failed to provide lasting reductions in stigma overall (2). However, a community-based approach provides a means of utilizing contact (2). The influence of opinion leaders in a community and the use of community discussions on interventions could lead to changing attitudes towards infected people.
As with the other high-risk populations, interventions need to employ the power of the community and social networks. The community can help develop effective programs that target the at-risk populations. In order to affect a difficult to reach group the intervention needs to utilize the community to adapt to the group dynamics. No individual health official understands the community as well as the members.


Conclusion and Discussion
While many factors affect the behaviors of at-risk populations, perceived levels of stigma can predict possible behavior change. The presence of stigma has negative effects on public health interventions and leads people living with HIV/AIDS to avoid health services. Sivaram et al., when looking at social capital and HIV stigma in consideration for HIV/AIDS prevention intervention design, stated that stigma manifests from “social norms that render an attribute or condition inferior or inappropriate” (13). These social norms lead to reactions of fear and perceived threat (13). Under this perceived threat, people living with HIV/AIDS find difficulty in seeking health and medical services.
Beyond perceived threat, Sivaram et al. found situations where clinicians refused care to infected people (13). When an example such as this happens, stigma finds a new hold among the population. Trepidation can cause victims of stigma to avoid health and medical services. This not only makes intervention efforts ineffectual, but also creates a high risk dynamic. Stigma leads people to develop negative self-feelings and these feelings lead people to seek validation. Engaging in high-risk behaviors because of feelings of low self-worth not only puts the individual in danger, but the rest of the population. Sivaram et al. speculates that individuals hesitate to engage in prevention and care-seeking behaviors because they anticipate discrimination and possible violence (13).
HIV/AIDS interventions need to focus on community-level approaches. Most importantly, interventions should involve the community in the development of prevention programs. In this way, the program can identify key community members and opinion leaders. These influential leaders can help adapt the intervention to the group dynamics. Outside of opinion leaders, the community can help develop proper implementation methods for the intervention. Community members understand how the population digests information and ideas; their ideas can help the intervention penetrate the population (6). Key to intervention success, social marketing helps open the door for prevention programs. Without social marketing, the key components of a successful intervention cannot find their audience.
In summary, interventions need to utilize opinion leaders, peer education, enhancement training, and prevention techniques to change behaviors in people living with HIV/AIDS. These techniques help to mitigate stigma among the population and surrounding community. The interventions must involve the community every step of the way to reduce fear of exposure. Stigma exemplifies a real fear of people living with HIV/AIDS and a true deterrent to successful interventions. Prevention programs can reach marginalized populations if confronting stigma becomes a focal point of HIV/AIDS intervention.
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