Self-esteem Instability and Its Implications for HIV Prevention among Gay Men

This study, using a modified State Self-Esteem Scale (SSES), examined self-esteem instability and its association with risky sexual behavior among 455 gay and bisexual men. A self-administered questionnaire included the SSES and measures of intimacy, loneliness, social support, and ways of coping. Analysis of variance showed that the self-esteem of participants who recently engaged in unprotected anal intercourse with nonprimary partners was more unstable than the self-esteem of participants who did not engage in unprotected anal intercourse. Self-esteem instability was associated with higher avoidance coping, higher loneliness, and lower social support. Episodes of self-esteem injury might motivate some gay men to engage in risky sex. HIV prevention strategies with gay men should target the quality of their interpersonal relationships and community supports. Key words gay men HIV/AIDS prevention self-esteem sexual practices State Self-Esteem Scale Although a majority of gay men appear to maintain safer sex habits designed to prevent HIV infection, a minority do not adopt such habits or else they do not maintain them (de Witt, van den Hoek, Sandfort, & van Griensven, 1993; Donovan, Mearns, McEwan, & Sugden, 1994; Ekstrand & Coates, 1990; Gold, 1995; Kelly, St. Lawrence, & Brasfield, 1991; McLean et al., 1994). Previous research on this population associated risky sexual behavior with many different variables including young age (Ekstrand & Coates, 1990), older age (McKusick et al., 1985), alcohol and drug use (Kelly et al.,1991; McKirnan & Peterson, 1989), monogamy (McKusick, Coates, Morin, Pollack, & Hoff, 1990; McLean et al., 1994), and having multiple partners (Ekstrand & Coates, 1990). However, there continues to be little understanding of the motivations for risky sexual behavior (Donovan et al., 1994). Such behavior seems to occur for a variety of reasons, and it may well be that a single set of variables cannot explain it in all gay men. Rather, gay male subpopulations as different as young versus old, ethnic minority versus majority, and "closeted" versus "out" may be vulnerable for different reasons. Increasingly, practitioners advance the notion that psychosocial factors, such as self-esteem, provide the motivation for both risky sexual behavior and maintenance of safer sex habits. Kellogg (Hartinger, 1992), a clinical social worker, claimed that risky sex is related to low self-valuation. Similarly, some psychologists have asserted that improving a gay man's self-esteem might reduce the likelihood of his engaging in risky sex. Gay Men's Health Crisis, a leading agency engaged in HIV prevention and treatment, stated that prevention could be enhanced by promoting "gay self-esteem" (Gay Men's Health Crisis, 1995). Among men participating in focus groups in San Francisco, some reported that low self-esteem was one obstacle preventing their attempts to maintain safer sex habits (Van Gorder, 1993). One man stated,"I did not value my life enough to prevent myself from getting up totally blasted and ending up as a receptacle for someone else" (Van Gorder, p. 7). The Ad-Hoc Committee of AIDS Service Providers coordinating these groups concluded that "AIDS prevention agencies, lesbian, gay, and bisexual community groups, and San Francisco's major institutions must unite in an unprecedented and innovative effort to respond to the emotional needs of gay and bisexual men" (p. 7). One strategy that the committee advanced was to build self-esteem. The theoretical association of low self-esteem with risky sexual behavior among gay men was also advanced by researchers such as Peterson, Ostrow, and McKirnan (1991). However, several studies examining this association in a variety of samples did not provide empirical support for it. Samples included 502 British men who had sex with other men during the previous five years (Fitzpatrick, Dawson, Boulton, McLean, & Hart, 1991), 383 sexually active gay and bisexual male clients of an outpatient substance abuse treatment facility in San Francisco (Paul, Stall, Crosby, Barrett, & Midanik, 1994), 637 sexually active gay and bisexual men in Chicago (O'Brien, Wortman, Kessler, & Joseph, 1993), 100 gay men in New York City (Siegel, Mesagno, Chen, & Christ, 1989), and 53 gay men in North Carolina (Perkins, Leserman, Murphy, & Evans, 1993). …