Avoidance Coping and HIV Risk Behavior among Gay Men.

During the 20-plus years since the HIV epidemic began in the United States, numerous researchers have attempted to uncover the determinants of sexual risk taking among gay men that might suggest effective prevention strategies. Much of the early research was based on theoretical models that assumed risky sexual behavior, like other health-related behaviors, could be changed through a rational decision-making process (for example, Becker, 1974; Fishbein & Middlestadt, 1989). For many years prevention efforts in the United States, which were based on the same assumption, had as their goal strict adherence to safer sex practices (Rofes, 1998). Although gay men initially made dramatic changes in their sexual behavior by adopting these practices (Becker & Joseph, 1988), many did not maintain them, and successive generations of gay men have not adopted them as consistently (Stall, Hays, Waldo, Ekstrand, & McFarland, 2000). More recently practitioners have developed prevention strategies based on negotiated safety, in which seronegative primary partners agree to engage in unprotected sex with each other and to use condoms if they engage in extra-relational sex. Although these strategies assumed a sexuality that is under rational control, as much as earlier ones did, they reduced the unreasonable expectation that gay men must engage in only protected sex for the rest of their lives. Recent evidence suggests that the effectiveness of even these strategies may be limited over time (Van de Ven, Rawstorne, Crawford, & Kippax, 2002). The prevalence of HIV infection among men who have sex with men (MSM) in the United States remains quite high (Catania et al., 2001; Koblin et al., 2000). At least one recent study reported an increase in the incidence of infection in this population (Coates et al., 2000), and this study and others reported increases in rates of risky behaviors (Fox et al., 2001; Wolitski, Valdiserri, Denning, & Levine, 2001). Although the self-report category "MSM" obscures evidence for men who identify themselves as gay, there is little reason to believe that the trends are any less disturbing among them. These trends suggest that the theoretical models underpinning HIV prevention practice among gay men may be considerably flawed, with research in this area having significant limitations. Some authors claim that American HIV prevention research has tended to be overly reductionist, focusing too much on static individual factors stripped of their interpersonal, interactive, and cultural context (Diaz, 1999; Henriksson, 1995; Wright, 1998). Such reductionism may be particularly problematic with respect to stigmatized minority populations such as gay men. In addition, this research has insufficiently examined the extent to which sexual behavior might not be subject to rational decision-making processes (Martin & Knox, 1997b; Wright). According to Coates and colleagues (2000), sexual behaviors "are basic, often urgent, and engaged in without complex cognitive analysis. A brochure can be informative on Tuesday morning; in a moment of intense passion on Friday night, a different analysis occurs.... for some individuals chronic loneliness, isolation, and alienation lead to remedies, which may include high-risk behavior" (p. 4). In light of these trends, acquiring a better understanding of the determinants of risky sexual behaviors among gay men is increasingly important. Toward this end, Martin and Knox (1995, 1997b) proposed adapting the diathesis-stress model (Oquendo & Mann, 2001), which theorizes that problematic behaviors occur among individuals with specific vulnerability factors when they encounter sufficient environmental stress. In their adaptation of the model, Martin and Knox (1995, 1997b) suggested that risky sexual behavior may be activated episodically when individuals with particular vulnerabilities (for example, unstable self-esteem, loneliness, and reliance on avoidance coping) encounter sufficient environmental stress (for example, lack of support and intimacy, antigay discrimination, and threats of or actual violence). …