ASSOCIATIONS WITH SEXUAL HEALTH BEHAVIORS AND ATTITUDES By ASHLEY L. MCLAIN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN MASS COMMUNICATION UNIVERSITY OF FLORIDA 2014
Â© 2014 Ashley L. McLain
To Lucy and Sesame
4 ACKNOWLEDGMENTS I want to take this opportunity to express my deepest thanks to my thesis chair, Dr. Walsh Childers, for her continued patience, guidance, motivation and feedback every step along the way of this challenging process. I also would like to thank my committee members, Dr. Treise and Dr. Morton, for their continued suppor t and interest in my work. Thank you to my wonderful family for their never ending support and encouragement, and to my dear friends Kristen Lewis and Jennie McKeon for never f this.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 ABSTRACT ................................ ................................ ................................ ..................... 8 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ ....... 10 Sexually Transmitted Infections ................................ ................................ ............................. 11 Unplanned Pregnancies ................................ ................................ ................................ ........ 15 Sexual Health Behaviors ................................ ................................ ................................ ....... 17 Sexual Health Risk Behaviors ................................ ................................ ............................... 18 2 LITERATURE REVIEW ................................ ................................ ............................. 33 Theoretical Perspective ................................ ................................ ................................ ......... 33 Media and Sexual Health Behaviors ................................ ................................ ...................... 34 Sex Education and the Interne t ................................ ................................ ............................. 40 Sexually Explicit Websites: Prevalence and Effects ................................ .............................. 41 Pornography as a Public Health Issue ................................ ................................ ................... 47 Hypotheses ................................ ................................ ................................ ........................... 49 3 METHODS ................................ ................................ ................................ ................ 51 Data Collection ................................ ................................ ................................ ...................... 51 Sample Population ................................ ................................ ................................ ............ 51 Sample Recruitment ................................ ................................ ................................ .......... 52 Instrument ................................ ................................ ................................ ......................... 53 Operational Definitions ................................ ................................ ................................ .......... 54 Measures ................................ ................................ ................................ .............................. 55 Use of SEIM ................................ ................................ ................................ ...................... 55 Sexual Risk Behaviors ................................ ................................ ................................ ...... 56 Attitudes Toward Pornography ................................ ................................ .......................... 59 Attitudes Toward Condom Use ................................ ................................ .......................... 61 Demographics ................................ ................................ ................................ ................... 64 Data Analysis ................................ ................................ ................................ ........................ 64 4 RESULTS ................................ ................................ ................................ .................. 65 Sample Characteristics ................................ ................................ ................................ ......... 65 Tests of Hypotheses ................................ ................................ ................................ ............. 72 5 DISCUSSION ................................ ................................ ................................ ............ 83 Study Findings ................................ ................................ ................................ ...................... 83 General Characteristics of the Study Respondents ................................ ........................... 83 Hypotheses Findin gs Compared to Previous Research ................................ ..................... 87 Findings in Relation to Theoretical Framework ................................ ................................ .. 91 Limitations ................................ ................................ ................................ ............................. 92 Subject Pool and Sample Size ................................ ................................ .......................... 92 Nature of the Study ................................ ................................ ................................ ........... 93 Future Research and Implications ................................ ................................ ......................... 93 Conclusion ................................ ................................ ................................ ............................ 96
6 APPENDIX A STUDENT SURVEY ................................ ................................ ................................ . 97 B STUDENT RECRUITMENT LETTER ................................ ................................ ..... 105 REFERENCES ................................ ................................ ................................ ............ 106 BIOGRAPHICAL S KETCH ................................ ................................ .......................... 113
7 LIST OF TABLES Table page 4 1 Demographic characteristics of sample population. ................................ ........... 75 4 2 Sexual activity by age. ................................ ................................ ........................ 76 4 3 Use of SEIM. ................................ ................................ ................................ ...... 77 4 4 Descriptive statistics for scales. ................................ ................................ .......... 78 4 5 Descriptive statistics for scales by rac e ................................ .............................. 79 4 6 Linear regression: SEIM as a predictor of sexual risk behaviors. ....................... 80 4 7 Linear regression: attitude toward pornography as a predictor of attitudes and behaviors, standardized regression coefficients (Betas) ................................ .... 81 4 8 Linear regress ion: attitudes toward pornography and SEIM use as a predictor of sexual health behaviors. ................................ ................................ ................. 82
8 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the R equirements for the Degree of Master of Arts in Mass Communication C ASSOCIATIONS WITH SEXUAL HEALTH BEHAVIORS AND ATTITUDES By Ashley L. McLain August 2014 Chair: Kim Walsh Childers, PhD Major: Mass Communication A sampl e of 85 undergraduate males completed an online survey to determine if their use of sexually explicit Internet material (SEIM) was associated with sexual health behaviors and attitudes toward pornography and condom use. The study was based on the Social Co gnitive Theory, which suggests that when individuals witness behaviors that are either rewarded or without negative consequences, they are more likely to imitate those behaviors. It was hypothesized that exposure to SEIM would negatively affect sexual heal th by decreasing condom use and partner communication and increasing riskier sexual health behaviors. Additionally, it was predicted that attitudes toward pornography would be associated with attitudes toward condoms. Hypotheses were tested with Linear Reg ression after One Way ANOVA Means Tests identified whether control variables were needed for demographic variables. SEIM exposure was a statistically significant predictor of condom use only for males who reported their race as other, and of risky sexual h ealth behaviors. SEIM was not a predictor of partner communication. For black males, a positive attitude toward pornography was a predictor of less positive condom use attitudes. Post hoc analyses revealed that sexual risk
9 behavior increased as positive at titudes toward pornography increased; exposure to SEIM increased as positive attitudes toward pornography increased for white males; and controlling for SEIM exposure, risky sexual health behaviors increased as positive attitudes toward pornography increas ed. Further research is needed to determine if the associations exist among other populations and to further investigate the role that race and sensation seeking may have on these associations.
10 CHAPTER 1 INTRODUCTION Despite the fact that the general hea lth of the population has continued to advance, the United States is fighting a losing battle in terms of the sexual health of young adults. It has been estimated that even though young adults account for only a quarter of the sexually experienced populati on, they are responsible for almost half of the 19 million new sexually transmitted diseases each year in the United States. These rates translate to 9.1 million new sexually transmitted infections (STI) diagnosed each year in youth ages 15 to 24. These ST I diagnoses put the United States in the lead for highest rates of gonorrhea and Chlamydia when compared to young adults in Canada and Western Europe (Darroch, Frost, Singh, & The Study Team, 2001; Guttmacher Institute, 2011; Weinstock, Berman, & Cates, 20 04). and on phones basically anywhere at any time, as private or public as you want. The U.S. Census showed that in 2012, 78.9% of households in the United States had a comp uter at home, with 94.8% of those households using the computer to access the Internet (U.S. Census, 2012). In addition, the Pew Internet & American Life Project (2013) found that 85% of adults 18 to 29 years of age accessed the Internet via mobile phone ( Duggan & Smith, 2013). This high level of Internet access may be connected to the proliferation of sexually explicit Internet material in our daily lives. In 2012, 420 million pornography sites flourished on the Internet with 25% of all daily search engine requests being for pornographic material (Ropelato, 2012). With this much access to unrealistic portrayals of sexual behaviors, which rarely depict healthy behaviors such as condom use and partner communication, it is necessary to consider whether it may play
11 a role in modeling sexual health behaviors or attitudes for the young adult population disproportionately contracting sexually transmitted infections. As a result, the current study investigated whether the use of and attitudes toward sexually expli cit Internet material may shape the sexual health attitudes and behaviors of young adults. The remainder of Chapter 1 presents the purpose and significance of the study by showcasing the state of sexually transmitted infections and unwanted pregnancies in the young adult population, with connection to behaviors that promote sexual health as well as risky sexual health behaviors. The literature review, impact on sexual he theoretical framework of the study. Chapter 3, Methodology, describes and justifies the data gathering process and data analyses. In Chapter 4, the results of the research are presented; conc lusions and implications of these findings are discussed in Chapter 5, Discussion. Sexually Transmitted Infections In the United States, women 20 24 years old have the highest rates of Chlamydia 3,695.5 cases per 100,000 females while women 15 19 have the second highest rates 3,291.5 cases per 100,000 females. From 2008 to 2011, Chlamydia rates increased 18.1% among women ages 20 24 and 8.9% among women 15 19. For males, during 2011 to 2012, Chlamydia rates increased from 254.4 to 262.6 cases per 100,000, a 3.2% increase. The highest rates were among men ages 20 24, 1,350.4 cases per 100,000. In terms of race, black men and women had significantly higher chlamydia rates compared to other racial groups. To put these rates into perspective, in
12 2012, Chlamydia was the most commonly reported notifiable disease in the U.S. (CDC, 2013). Although Chlamydia is often asymptomatic, it can have lasting consequences. According to the Centers for Disease Control, Chlamydia is so easily spread and underreported because m any people do not realize they have contracted it until much later in their lives. Chlamydia can be passed from one individual to another through oral, vaginal or anal sexual intercourse. If left untreated in women, it can develop into pelvic inflammatory disease, which can cause permanent damage to the female reproductive system, resulting in chronic pain, infertility and ectopic pregnancies, which, in some cases, can be fatal. Although rare, untreated Chlamydia in men may result in skin lesions, pain and sterility (Chlamydia CDC Fact Sheet, 2011). Gonorrhea rates have also continued to rise among men and women, and the disease is now the second most commonly reported notifiable disease in America. Women had the highest rates, with 578.5 cases per 100,000 for ages 20 24 and 521.2 cases per 100,000 for ages 15 19. The highest rates for men (462.8 cases per 100,000) were among men ages 20 24, accounting for an overall rate increase of 9.8% for both genders from 2011 to 2012. Rates continue to be highest amon g black men and women (CDC, 2013). Although gonorrhea is easily curable, many cases go untreated and undiagnosed because it is often asymptomatic. In women, untreated gonorrhea can lead to pelvic inflammatory disease, ectopic pregnancy, infertility, and d evelopment of scar tissue that can not only block the fallopian tubes, but can also cause long term pelvic and abdominal pain. For men, untreated gonorrhea can cause sterility. Both men and
13 women may also be at an increased risk for contracting HIV if they have gonorrhea (Gonorrhea CDC Fact Sheet, 2014). Syphilis rates also have continued to increase among male and female young adults since 2002. These rates are highest among males between the ages of 20 to 24, with rates of 24.5 cases per 100,000 people, resulting in an increase of 46.2% since 2008. Rates for females aged 20 24, the female age group with the highest incidence of syphilis, also increased during this time period, from 3.7 to 3.9 cases per 100,000. In terms of race, black men and women have the highest rates of syphilis compared to other racial categories (CDC, 2013). Syphilis is contracted through skin to skin contact with syphilis lesions on the genitals, anus, lips or mouth; as a result, transmission occurs though oral, vaginal or anal sex . People often remain undiagnosed for long periods of time because the sores are not recognizable immediately and, meanwhile, the infected person is still capable of spreading syphilis to his or her partners. If syphilis remains untreated, it can progress to internal organ damage, resulting in paralysis, dementia or blindness; however, cases such as these are rare. Untreated syphilis may also facilitate the transmission of HIV and may cause perinatal death in up to 40% of cases if pregnant women remain untr eated (CDC, 2013; Syphilis CDC Fact Sheet, 2014). While many sexually transmitted diseases may resolve with medication, one that does not is genital herpes. In the United States, approximately one of six people between the ages of 14 to 49 have genital he rpes. The virus is transmitted from sexual contact with an infected individual. The disease can be transmitted even when an
14 causing painful sores that break into ulcer s, take weeks to heal, disappear and then reappear all over again. There is no cure for herpes (Genital Herpes CDC Fact Sheet, 2014). Today, approximately 50 percent of sexually active individuals will be diagnosed with HPV in their lifetimes, with nearly 35 percent of teenage females currently infected (CDC Sexually Transmitted Diseases, 2009; CDC, 2010, May 28). Currently, there are approximately 79 million Americans infected with HPV, with 14 million new infections each year (HPV CDC Fact Sheet, 2014). H PV is transmitted through oral, vaginal or anal sex or direct skin to skin contact with an infected person. Among the more than 40 strains of HPV, some can result in warts on the genitals or throat. More seriously, HPV may cause cancer of the cervix, vulva , vagina, penis, anus, tongue, throat and tonsils. One of the reasons HPV has spread so rapidly is that individuals can go years after being infected without symptoms, all the while spreading the virus to new partners, who in turn pass along the virus to a ll their subsequent partners (Genital HPV Infections CDC Fact Sheet, 2011). Although a HPV vaccination was approved for use in males and females 9 26 years of age to protect against four types of HPV, the vaccination uptake has been low 33% of females age d 13 17 received all three required doses of the vaccine with even few males receiving the vaccine. In addition, tests that can clearly screen for HPV have not yet been approved. Moreover, the CDC stresses that condoms may reduce the risk of HPV, but that there are few prospective epidemiological studies showing that condoms can protect individuals from acquiring genital HPV (Condoms and STDs CDC Fact Sheet, 2014). Apart from the aforementioned health effects, sexually transmitted
15 infections also have lasti ng psychological effects on the individual and their relationships (CDC, 2013; Genital HPV Infections CDC Fact Sheet, 2011). Though many youth may believe they are unlikely to contract HIV, the CDC (2014) stresses that this population is at significant ri sk based on the prevalence of early sexual initiation and unprotected sex. In 2010, 26% of new HIV infections were in youth ages 13 24, accounting for 12,200 of 47,500 new HIV infections. Of all the age groups newly diagnosed with HIV, 20 to 24 year old y oung adults had the highest rates of diagnoses. HIV is a risk for those engaging in sexual risk behaviors, regardless of sexual orientation; however, black youth and homosexual males have disproportionately higher HIV rates. In addition, those who have pre viously acquired an STI other than HIV have a greater chance of contracting and transmitting HIV (HIV Among Youth CDC Fact Sheet, 2014). Unplanned Pregnancies Sexually transmitted infections are not the only consequences of risky sexual health behavior. Unplanned pregnancies may also result from such behavior (Kaye, Suellentrop, & Sloup, 2009). Each year in the United States, approximately half of all pregnancies are unintended. Young women between 18 and 24 have the highest rates of unplanned pregnancie s of all age groups, meaning that approximately one unintended pregnancy resulted for every 10 women. Although unintended pregnancies among teens have continued to decline, the proportion of unintended pregnancies for women aged 20 24 have increased from 5 9% in 2001 to 64% in 2006. Studies on unintended pregnancies consistently demonstrate strong disparities: most unwanted pregnancies occurred among low income women, black women, and women who had not obtained a high school diploma. Young women who were in college or had
16 completed a college education had lower rates of unintended pregnancies than women reporting lower educational levels. In addition, the rate of unintended pregnancies for college graduates decreased from 1994 to 2001 (Finer & Zolna, 2011; Mo sher, Jones, Abma, 2012; Finer & Henshaw, 2006). A nationally representative survey of 18 to 29 year old young adults conducted by Kaye, Suellentrop and Sloup (2009) for the National Campaign to Prevent Teen and Unplanned Pregnancy revealed striking infor mation about the state of unplanned pregnancies in the United States. Seventy percent of pregnancies to unmarried women in their 20s are unplanned. In terms of beliefs about whether pregnancies should be planned, there were differences among men and women: 74% of men strongly agreed that pregnancies should be planned, while only 64% of women strongly agreed. This difference in statistics was similar for single young adults: 76% of single males strongly agreed in comparison to 67% of single females. At the p oint they are in their lives right eeded to avoid an unplanned pregnancy. Despite these intentions and knowledge about how to avoid pregnancy, the young adults did not report consistent action to protect against pregnancy. Among unmarried young adults who are in sexual relationships but n ot ready to have a child, 19% reported not using contraception at all, 24% reported inconsistent use and 7% were unsure whether contraception was being used. Even among those with the strongest intentions to avoid pregnancy, contraception use still did no t match up. Of the
17 respondents who said it was very important to avoid pregnancy at this point in their lives, 34% reported they likely will have unprotected sex in the near future. With these behavioral findings, it is not surprising that 31% of the young women reported having an unplanned pregnancy while nearly 70% reported that many of their friends had experienced unplanned pregnancies (Kaye, Suellentrop, & Sloup, 2009). Sexual Health Behaviors As the following research will demonstrate, college stud ents and young adults may be more susceptible to participating in sexual risk behaviors and thereby more likely to contract sexually transmitted infections or an unplanned pregnancy because of several factors. These factors may include: substance abuse, la ck of sexual health knowledge, attitudes toward condoms, and the rising prevalence of a casual sex culture among young adults (Cho & Span, 2010; Benotsch, Koester, Luckman, Martin, & Ceika, 2011; DiClemente, Sales, Danner & Crosby, 2011; Hill, Amick, & San ders, 2011; Downing Matibag & Geisinger, 2009; Bailey, Fleming, Henson, Catalano & Haggerty, 2008; Bailey, Haggerty, White & Catalano, 2011; Bersamin, Pachall, Saltz & Zamboanga, 2012; Grello, Welsh & Harper, 2006; Fielder & Carey, 2010; Furman & Shaffer, 2011; Olmstead, Pasley & Finchman, 2013). In addition, young adults are inundated with models of risky sexual behaviors from traditional media, as well as from pornography (Collins, Elliott, Berry, Kanouse, Kunkel, Hunter & Miu, 2004; Farrar, 2006; Ward & Friedman, 2006; Braun Courville & Rojas, 2009; Luder, Pittet, Berchtold, Akre, Michaud & Suris, 2011; Peter & Valkenburg, 2008; Goodson, McCormick & Evans, 2001; Morgan, 2011), increasing the need for investigation into whether young adults may be modeling their own behaviors after these unhealthy portrayals.
18 Previous research has demonstrated that the percentage of pornography exposure for young adults was as high as 92% for college males, with 58% of this portion viewing sexual content on the Internet at least once a week (Morgan, 2011); for adolescent males, the exposure was as high as 86% in separate research (Morgan, 2011; Braun Courville, & Rojas, 2009). With the tech savvy young adult population of the United States being responsible for such a lar ge percentage of sexually transmitted infection cases, it is important to investigate whether exposure to readily available sexual content on the Internet may be correlated with a change in sexual health attitudes or behaviors. As a result, this study exam and its effect on their sexual health attitudes and behaviors. The study presents previously published research explaining why unprotected and risky sexual health behaviors are so common among young adults. The current review (Chapter 2) will emphasize research on how the media portray sexual health behaviors and how these portrayals may affect the attitudes and behaviors of young adults. Because of the sensitive nature of the topic, an online survey was utilized; further explanation of the survey will be provided in Chapter 3. Sexual Health Risk Behaviors To accurately examine the causes of such high numbe rs of sexually transmitted infections in the young adult population it is necessary to reference the high participation in sexual health risk behaviors. These behaviors may include, but are certainly not limited to: substance abuse, lack of sexual health knowledge and a prominent casual sex culture among young adults.
19 Alcohol has long been studied in connection to health behaviors. Recently, Cho sexual risk behaviors. T his experimental study utilized a video vignette of a couple who meet at a party and show interest in one another. The participants, aged 21 to 30 years old, were asked to report what type of sexual behavior they would engage in if they were part of the co uple in the situation. The researchers found that women who thought they would have been drinking alcohol in the situation reported a greater likelihood of engaging in sex than those who thought they had not. Contrastingly, males who thought they would hav e drunk alcohol were significantly less likely to report they would have sex in this situation when compared to the men who expected to remain sober. Alcohol use was not shown to be an indicator for condom use; however, past condom use was a predictor for expected condom use in the experiment (Cho & Span, 2010). While the definition of substance abuse was once primarily concentrated on alcohol, it has been expanded to include the relationship between prescription drug abuse and sexual risk behavior. Benot sch, Koester, Luckman, Martin, and Ceika (2011) examined the relationship between nonmedical use of prescription drugs (NMUPD) and sexual risk behavior. Analyses of a survey administered to a sample of undergraduate students (ages of 18 to 25) revealed tha t 36% reported NMUPD sometime in their lifetime, with 22% reporting use in the three months leading up to the survey. Most relevant for this study was that the researchers found an association between NMUPD use and sexual risk behavior. More specifically, the use of NMPUD was associated with having multiple sexual partners, unprotected sex, and use of illegal drugs, such as marijuana, ecstasy or cocaine, or alcohol substance abuse prior to sex. When
20 compared to those who had not engaged in NMUPD users, tho se who had were found to have more sexual partners and more unprotected sex (Benotsch et al., 2011). contribute to their participation in sexual risk behavior. DiClemente, Sales, Danne r, and health behavior and their lab confirmed sexually transmitted disease test results. The nationally representative sample was composed of respondents from the National L ongitudinal Study of Adolescent Health more than 14,000 young adults who participated in three waves of the survey. For the purposes of this study, the researchers used interview data from participants at wave three, as well as a biological specimen that was tested for sexually transmitted diseases. Ironically, the results of the study revealed a disparity between reported abstinence and testing positive for an STI. The researchers found that more than 10% of those who tested positive for an STI had repo rted they had been abstinent in the past year. It is important to note, however, that these STIs could be resulting from an infection that was acquired before the year of the study. The researchers found there were no sociodemographic factors significantly associated with the incongruent answers between reported sexual health history and positive STI results. This research demonstrates that self reported sexual health behavior is not always the most accurate assessment for sexual health among young adults. Furthermore, one could reason that the study demonstrates the lack of sexual health knowledge in young adults who may not realize they can contract STIs from acts other than vaginal intercourse (DiClemente et al., 2011).
21 Because of the relationship that a ttitudes may have with behaviors, Hill, Amick and Sanders (2011) developed the Brief Condom Attitudes Scale. The researchers administered an online survey to college students to assess their attitudes toward condoms and condom use. The study demonstrated t hat when compared to women, men were significantly more likely to view condoms as an interruption to sex. Additionally, men were significantly more likely to view condoms as protective in that they believed they successfully protected them from sexually tr ansmitted infections and unplanned pregnancies. Women were less likely to view condoms as protective. Interestingly, male and female respondents that reported being in a monogamous sexual relationship during the six months before the study were less likely to have negative attitudes toward condoms than single respondents. The research demonstrated that condom attitudes may be multidimensional for college students in that there are several positive and negative aspects that should be examined when assessing condom attitudes rather than just assessing attitudes toward condoms as positive or negative. Perhaps the strongest contributor to the prevalence of sexually transmitted infections in young adult college populations is the increasing normalization of casu al sex behaviors. For many young adults, casual sex behaviors begin with their transition into the college environment (Fromme, Corbin, & Kruse, 2008). One study that Fle ming, Henson, Catalano, and Haggerty in 2008. The study focused on sexual risk behavior in the period six months after high school completion. In terms of sexual risk behaviors, the researchers collected data related to casual sex, condom use and high -
22 risk sex. The study involved data obtained from the Raising Healthy Children survey project administered to more than 800 high school seniors who were re surveyed six months after they graduated high school. The researchers found that college students were les s likely to engage in sexual risk behavior than students not enrolled in college. Despite the lower prevalence, however, 23% of the college students engaged in unprotected sex. Of the total sample, 30% reported their condom use behavior as inconsistent, 23 % reported participating in casual sex, and 11% reported participating in high risk sex, such as unprotected sex, sex with HIV positive partners or intravenous drug users (Bailey et al., 2008). Multivariate analyses revealed a significant statistical rela tionship between being in a relationship, college attendance and consistent condom use. The statistical relationship illustrated that students were inconsistent with their condom use when they were in a relationship. Further, high school grade point averag e was positively associated with consistent condom use in the sample surveyed after high school. College attendance and living in a household with a parent were both found to be predictive of a lower probability of engaging in casual sex. In addition, coll ege attendance was found to be a predictor of refraining from high risk sex (Bailey et al., 2008). In 2011, Bailey, Haggerty, White, and Catalano published an extension of the previously mentioned work. In the more recent study, the researchers examined t he correlations between sexual risk behavior and a variety of characteristics, including relationships, living situations, college attendance, and work. As in the previous study, sexual risk behavior was assessed based on three factors: casual sex; condom use
23 consistency; and engagement in high risk sexual activity. The sample for the survey consisted of 801 participants who had originally been surveyed two years earlier, while they were still in high school. The researchers found that respondents who repor ted living with a parent were less likely to report participating in high risk sex, casual sex, or inconsistent condom use. Those in the sample who reported being in a relationship were more likely to use condoms inconsistently, but less likely to engage i n casual sex. As was found with the previous study, high risk sex was less likely to be reported by college attendees than those not attending college (Bailey et al., 2011). Similarly, Fielder and Carey (2010) examined the effects of the "hookup" or casual sex behavior in students during their first semester of college. The researchers investigated what predicts "hooking up" and how the behavior affects students first semes ter of college. The study sample was composed of 140 freshman college students ages 18 to 19. The researchers measured demographic information, religiosity, oral and vaginal sex behaviors before college, self esteem, distress, intentions to engage in oral or vaginal sex with a casual partner in the next semester, and social norms. The data obtained were used to generate four outcome models in order to predict behaviors. The models included: oral and vaginal sex hookup behavior and number of vaginal and oral sex hook up partners. Three behaviors were found to predict hookup outcomes in the sample population: number of casual partners; prior casual hookup behavior; and peak the number of alcoholic drinks they consumed on their self
24 of hours over which the drinks were consumed. Interestingly, the researchers found that students who had reported a set limit for the number of casual sex partners they would have at the start of the study were less likely to report intercourse during the study. In addition, when students rated parental disapproval of sexual relationships as high, they were more likely to have more oral sex partners. The investigation of the psychological ychological distress in females and engaging in hookups. On the other hand, males who were not engaging in sex hookups were more likely to experience psychological distress. Fielder and Carey connected this finding to previous research demonstrating that m ales often tie their masculinity and high self esteem to a high number of sex partners and a belief that if they are not having casual sex, they are missing out on an experience other men are having (Fielder & Carey, 2010; Walsh, 1991; Pleck, Sonenstein & Ku, 1993). Bersamin, Paschall, Saltz and Zamboanga (2012) studied the relationship between college drinking settings and casual sex. The study assessed several setting level characteristics, student level variables and college level variables. For example , researchers examined situations in which sex with a stranger occurred to see if alcohol was involved, as well as whether participants who reported casual sex also reported attendance in drinking settings, such as bars or Greek parties, and the number of times they were drunk at these drinking settings. Student level variables were examined based on sexual experience, basic demographics, and the frequency of their heavy drinking episodes. In addition, the colleges the respondents attended were also taken
25 i nto consideration and examined based on demographic information about the schools, including racial diversity on campus, size of student body, and percentage of student body participating in Greek life. The researchers found that the settings in which col lege students chose to drink related to their likelihood of casual sex with a stranger. Casual sex with a stranger was found to be 10 times more likely to occur during or after a fraternity or sorority party and four times more likely to occur during or af ter a residence hall party or off campus party. As expected, researchers found that males and those who reported heavy drinking were more likely to engage in alcohol related sex with a stranger (Bersamin et al., 2012). Grello, Welsh and Harper (2006) inves tigated the circumstances involving casual sex in a college student population from a psychological perspective. The sample was composed of approximately 400 undergraduate students attending public colleges in the southeastern United States. The researcher s investigated the relationships of casual passionate love, game playing love, friendship love, practical love, neurotic love, and altruistic love, sexual behaviors and dep ressive symptoms. Analyses revealed that more than half of the sample responded that they had engaged in casual sex, with significantly more males than females reporting this behavior. In addition, students who reported having participated in casual sex al so reported having more sexual partners than their counterparts who did not report engaging in casual sex. In terms of substance abuse, 65% of students reported using alcohol or drugs prior to a casual sex episode. Casual sex partners were most likely to h ave been a stranger (37%) or a friend who was a nonromantic interest (63%) (Grello, Welsh & Harper, 2006).
26 As predicted, the researchers found gender differences in the outcome expectations for casual sex. Females reported believing that their last casual sex episode was "the beginning of a romance" (18%), "the beginning of a casual sex relationship" (16%), an "experimentation" (14%) or "just a one time thing" (52%). On the other hand, only 3 percent of males reported that their last instance of casual sex was "the beginning of a romance;" significantly higher percentages of males, compared to females, said the incident was "the beginning of a casual sex relationship" (33%), an "experimentation" (7%), or "just a one time thing" (57%). In terms of infidelity, researchers found that 21% of the sample who reported engaging in casual sex also reported that they had a romantic partner (other than the casual sex partner) at the time of the event (Grello et al., 2006). Furman and Shaffer (2011) examined the sexual b ehavior that occurs within different types of casual sex relationships during young adulthood. Relationships were broken down into the categories of romantic partners, friends, casual acquaintances ual sexual relationship between two friends with no commitment. Behaviors were grouped as light nongenital acts, such as making out, heavy nongenital acts such as petting or dry sex, and genital acts. Participants were gathered from the fifth wave of a lon gitudinal study, with the final sample consisting of 163 legally single young adults between 19 and 22 years of age. Analyses revealed that different behaviors were associated with different types of relationships or types of partners. First, respondents w ere more likely to have participated in sexual behavior with romantic partners (81%) than with nonromantic partners such as friends, acquaintances or friends with benefits. However, there were
27 still high frequencies of sexual behaviors with nonromantic par tners (66%). In addition, friends or acquaintances. Further, women in the sample were more likely to engage in sex with a romantic partner than men were. Furman an d Shaffer (2011) stressed this gender difference may be due to differences in interpretations of types of relationships not have participated in the study. Females migh t have had partners too old to have been included, while males might have had partners too young to be included, contributing to the different findings about sex in romantic relationships. In terms of defining "friends with benefits," respondents most ofte n reported that in a "friends with benefits" relationship, sex had to occur more than once, more often than with other friends or acquaintances, and the behavior had to include sex and not just light nongenital behavior. In addition, the two people in the relationship had to actually be friends for it to be considered a "friends with benefits" relationship. Olmstead, Pasley and Fincham (2013) investigated hooking up in a college male population and the correlation between individual, social, relational and family characteristics, the likelihood of hooking up and the type of hookup. The study involved a sample of 412 undergraduate college males between 18 and 25 years of age. The respondents completed an online survey at three waves in one school year. Indepe ndent individual variables included attitudes toward sex, religion, relationship awareness, personality, and previous hookup experience. The independent social variable was alcohol use. Independent relationship variables included relationship status and ty pe of relationship. Independent family variables included family structure
28 and perceived parental conflict. The dependent variable of the study was whether the participant had engaged in hookup behavior during the course of the study. Nearly 70% of partici pants reported hooking up within the timeframe of the study. Of these hookups, 73% involved oral sex or intercourse, with the majority of hookups involving intercourse with or without oral sex. In addition, participants who reported hooking up reported hav ing more than one partner during the course of the study. A little more than 20% of participants reported being involved in a committed relationship. Of these participants, 44% reported hooking up with individuals outside of their relationship, with nearly 70% of these hookups involving oral sex or intercourse. When comparing students who had hooked up with those who had not, a history of hooking up was the most influential factor for predicting future hookup behavior, followed by alcohol use and relationsh ip status. Males who had a history of hookups involving oral sex or intercourse were 184% more likely to have the same type of hookups in the future. Unlike other studies, Olmstead et al. (2013) were not able to establish a connection between alcohol and h ookups involving oral sex and intercourse. However, the analyses did reveal a correlation among men between a history of hooking up and permissive attitudes about sex; if a participant was more approving of uncommitted sexual behavior, they were more likel y to have hookups involving oral sex or intercourse. Downing Matibag and Geisinger (2009) took a different approach to the investigation of the "college hookup" behavior and found many misconceptions about sexual health behavior among young adults. The res earchers utilized qualitative content analysis of interviews conducted with college students about their experiences with
29 casual sex. The sample involved interviews with 71 college students at one university. The interviews focused on four main points: stu dents' perceptions of sex, norms of dating and hooking up at their college; the students' most recent hookup experience; the students' overall experience with hooking up in their sexual history; and, finally, students' perceptions about STIs in relation to hooking up. The interviews with the students revealed several key themes pertinent to research on the sexual health of college students. In terms of the students' perceived susceptibility to sexually transmitted infection, there was a wide disparity betwe en perceived risks of intercourse and of oral sex. Approximately half of the students reported concerns about contracting an STI from intercourse, while very few only 5% of the sample were concerned about contracting an STI from oral sex. Not a single student who was interviewed reported using protection during oral sex. Moreover, the researchers describe students' responses to questions regarding protection during oral sex as confused or appalled by the thought. The researchers were able to divide the reasons for college students in their sample believing they were invincible to STIs into three categories: trust in partners, trust in community statistics, and lack of knowledge about STI risk, especially with oral sex (Downing Matibag & Geisinger, 2009). The researchers found several explanations for why students may not use protection during sex. First, students expressed an overall perception that the costs associated with using condoms during hookups were higher than the benefit of avoiding an STI. Stu dents said that using condoms could cause a loss of opportunity or ruin the mood as well as interfering with the pleasure of the experience. Second, students described a lack of self efficacy in terms of performing protective sexual health behaviors. For
30 i nstance, a majority of students had no idea what type of protection was appropriate during oral sex, where to purchase it or how to communicate about it with their partner. Social norms appeared to heavily influence the level of behavior efficacy. For exam ple, several students reported they did not feel it was a normative behavior to use or ask a suggested a lack of efficacy with planning for protective methods prior to hookups (Downing Matibag & Geisinger, 2009). In terms of why students participate in sexual risk behavior, the most common reason was loss of inhibition due to alcohol use and the psychological aspect of being caught up in the moment. Within the interviews, 80% of students reported that alcohol was involved with their last hookup and was likely the reason for the progression of their behavior to sex. In addition, nearly 50% of students reported that they were caught up in the moment when their last hookup occurre d. The researchers stated that many of progressed as they had not planned for the hookup in the beginning (Downing Matibag & Geisinger, 2009). Similar high risk behaviors also are relatively common among University of Florida students. The 2009 University of Florida Sexual Health Student Survey gathered responses from just less than 1,000 randomly selected full time students between 2008 and 2009. The results from this survey ca n be grouped into three basic areas for the purpose of this paper: sexually transmitted infection testing, condom use, and pornography use. Far more students reported being sexually active than reported being tested for sexually transmitted infections (Gat orWell, 2009). STI testing rates were as
31 follows in the 12 months prior to the survey: 22.4% of students (29.3% of females, 10.6% of males) reported getting a Chlamydia test; 22.1% of students (29.1% of females, 10.2% of males) reported getting a gonorrhea test; 33.1% of students (41.5% of females, 18.5% of males) reported getting any STI test. The survey revealed inconsistent condom use rates among the sample population. Approximately 86% of students reported never using a condom during oral sex, and 32. 2% of the sample reported never using a condom during vaginal intercourse. In addition, 31.7% of sample reported always using a condom during vaginal intercourse, and 47.2% of sample used a condom the last time they had vaginal intercourse. During anal sex , 57% of sample reported never using a condom, while 32% of sample reported using a condom the last time they engaged in this behavior (GatorWell, 2009). Relevant to the present study, three quarters of students reported exposure to pornography. Overall, 7 5.1% of the sample (63.1% of females, 95.1% of males) reported ever viewing any type of pornographic material. In the past 30 days, 43.5% of sample (24.1% of females, 80% of males) reported viewing pornography. Among sexually active students, 78.6% report ed that they had ever looked at pornography, with 45.1% reporting use in the past 30 days. Of the students who were not sexually active, 63.3% reported that they had ever looked at pornography, with 38.0% reporting that they had looked at pornography in th e last 30 days (GatorWell, 2009). Traditional media formats television and film have been studied extensively in terms of their modeling of sexual health behavior and their ability to create sexual scripts for young adults to follow in their lives; thus, i t makes sense to investigate the
32 possibility of similar effects of pornography use. Today, Internet pornography is easily accessible, anonymous and becoming increasingly accepted, making the viewing of sexually explicit material an increasingly common beha vior, despite the fact that its (Ropelato, 2012; Smith, Gertz, Alvarez, & Lurie, 2000; Carroll, Padilla Walker, Nelson, Olson, Barry & Madsen, 2008; Perrin, Madanat, Barnes, Car olan, Clark, Ivins, Tuttle, sexually explicit Internet material and its effect on their sexual health attitudes and behaviors. Chapter 2 discusses research demonstratin emerging role of the Internet and sexually explicit Internet material as a sexual health model for young adults.
33 CHAPTER 2 LITERA TURE REVIEW Extensive research has been completed about media effects on sexual health behaviors, particularly media effects on youth. As the Internet has become such a consistent part of our daily lives, researchers have attempted to assess its positive a nd negative consequences. While a significant amount of research has addressed this topic in relation to teenagers and to young adult males in other countries, no studies could be found that addressed the impact of exposure to sexually explicit websites on the sexual health beliefs and behaviors of college age men in the United States. After reviewing research that has been completed about the Internet as a sex educator as well as a hub for sexually explicit websites, it is clear that pornography has become a public health issue . Theoretical Perspective Cognitive Theory (1997) suggests that individuals can not learn all of their behavioral patterns from experience or direct observation and thus must learn certain behaviors from other sources, including the media. In reference to the portrayal of sexual consequences in the media, the theory suggests that when individuals see other people similar to themselves participating in behaviors that either are rewarded or that are associated with no negative consequences, they are more likely to imitate these behaviors, believing there will be no negative consequences in their own experiences (Bandura, 1977; Bandura, 1997; McQuail, 2005).
34 Media and Sexual Health Behaviors sexual health behaviors; media exposure may be one of these factors. A significant body of research has been conducted on the impact of sexual content on TV on adolescents and young adults. Several studies have determined whether safe or unsafe sex portrayals on television affect the attitudes and behaviors of viewers (Collin s, Elliott, Berry, Kanouse, Kunkel, Hunter & Miu, 2004; Farrar, 2006; Ward & Friedman, 2006). attempted to address this topic. The experimental study found that watching depictions sex. More specifically, when women watched television programming lacking the depiction of condoms or safe sex dialogue, they had less positive attitudes about safe s ex and condom use. In comparison, women who viewed programming that included portrayals of condom use and safe sex messages were more likely to reflect positive attitudes about condoms and safe sex. It is important to note that viewing the same content did Sexual content on television could have lasting effects on the sexual scripts, attitudes and be haviors of teenagers that could continue into adulthood. Ward and Friedman (2006) found that teenagers who frequently watched what the researchers recreational sex. In the same study, the researchers found that the more exposure adolescents had to sex oriented television and other media types, the more likely they were to report sexual experience. However, it is important to note that, after controlling
35 titudes toward sex, the researchers found that the relationship strong as researchers once thought. Because these findings were associations rather than direct causal rela tionships, the researchers stressed the importance of acknowledging that adolescents with more recreational attitudes toward or experiences with sex might naturally select media content with sexual material. This suggests the need for future research in th is area to determine the relationship between established attitudes and viewing of sexual content on television and how that, in turn, influences 2006) assessed the movies, music and magazines. Through examination of the media diet, researchers sought to determine if sexual media diet is a predictor of sexual behavio r in adolescence. The longitudinal study was conducted with 1017 black and white adolescents between 12 and 14 years old, with follow up two years later. By examining the combined sexual media diet among the four types of media, researchers were able to c ompare the high sexual media diet participants to the low sexual media diet participants with regards to their sexual behaviors. The researchers found that within their sample, white adolescents with the highest sexual media diets were 2.2 times more likel y to have had sex at age of follow up (14 to 16 years old) when compared to the participants who reported the lowest sexual media diets. Interestingly, researchers found that the same did not apply to black adolescents, in whom parental
36 and friend expectat ions had a stronger influence on sexual behavior (Brown et al., 2006). While Brown et al. (2006) examined the total sexual media diet of adolescents, Fisher, Hill, Grube, Bersamin, Walker, and Gruber (2009) focused on the sole effect of television on ado this complex relationship. The study was cross sectional. The researchers utilized a sample of adolescents from the second wave of a three wave statewide longitudinal study. The study revealed that there was a relationship between exposure to sexually as intentions to engage in the behaviors in the next year. Further, increased exposure was related t o the perception that sex would not result in negative consequences health or otherwise but rather positive consequences (Fisher et al., 2009). Key to this study was the examination of the role parental involvement may play in reducing the effects of expo sure to sexy primetime television. Parental limits on what adolescents could watch and how long they could watch, as well as parental discussion of content, were associated with fewer negative effects of viewing sexual media content. For example, parental mediation of viewing was shown to be a significant factor for decreased likelihood of engaging in oral sex or intercourse in addition to increased perceptions that negative consequences could stem from sex. Contrastingly, the researchers found that increas ed parental discussion of sexual content on TV had a relationship with increased intentions to engage in oral sex. The researchers suggest that this may be due to parents witnessing their children viewing more sexually suggestive television, growing concer ned they may participate in sex soon and then
37 feeling the need to speak to them about the consequences. As a result of this, further investigation is needed into the role that parental involvement plays in sexual intentions of adolescents, particularly on a nationally representative scale (Fisher et al., 2009). To examine the relationship between sexual behavior and viewing of sexual media content, specifically whether adolescents who are engaging in sex are simply more likely to seek out sexual content in media and vice versa, Bleakley, Hennessy, Fishbein and Jordan (2008) conducted a longitudinal study of adolescents between 14 and 16 years old. The study revealed that the findings were two fold. First, adolescents who viewed sexual media content were mo re likely to advance in the levels of sexual activity they were participating in. Second, adolescents who were sexually active were more likely to seek out sexual content in their media diets. These findings demonstrate that exposure to sexual media can be both a cause and effect of sexual behavior in adolescents. Similar to Fisher et al. (2009), this study also investigated the relationship between parental involvement, viewing of media and sexual behaviors. The study revealed that adolescents whose parent s disapproved of them engaging in sex were more likely to seek out sexual media content. If the dual cause and effect relationship holds true, this could then lead to adolescents engaging in sexual behavior, which could lead to health consequences (Bleakle y et al., 2008). To investigate the relationship between television use, relationship status and sexual behavior, Fisher, Grube, Bermasin and Bourdeau (2010) conducted a longitudinal study of adolescents 14 to 18 years old. The study looked at relationshi p status, viewing of sexual content on broadcast cable networks, such as NBC, ABC,
38 CBS and FOX, and on premium cable channels, such as HBO, Showtime and Cinemax, overall television exposure and the sexual behavior of adolescents. The results revealed that there was a difference between adolescents viewing sexual content on premium cable and broadcast cable. While non sexually active youth were watching more TV overall, sexually active youth were more likely to be watching premium TV. Exposure to greater am ounts of sexual content on premium cable predicted a casual relationship at last intercourse for those who had engaged in sex. When applying the cause and effect relationships found within previously mentioned research, this finding is not unexpected, as p programming than broadcast programming, meaning adolescents who are exposed to more premium programming likely have more exposure to sexual content than those watching broadcast programming. This could have far reaching conseq uences as casual sexual relationships may be connected to more consequences than sex that occurs in committed relationships. In addition, youth who watched more premium cable television were also more likely to have friends who were sexually active. As in previous engagement in sexual behavior (Fisher et al., 2010). The researchers stressed the importance of investigating the relationship e to unregulated sexual content on the Internet and cell phones to further establish this possible relationship between viewing sexual content and sexual behaviors (Fisher et al., 2010). As Fisher et al. (2010) pointed out, the Internet can also serve as a point of exposure to sexual content for adolescents and young adults as it makes available a
39 vast array of sexually explicit material. A Pew Research study conducted in 2010 showed that 95% of college students were broadband Internet users, in comparison to 66% of the US population overall who are broadband users (Smith, Rainie, & Zickuhr, 2011). In addition, 2009 research found that half of college males spent three or more hours online each day, compared to one third of college females (Jones, Johnson Y ale, Millermaier, & Perez, 2009). There are a reported 420 million pornographic websites on the Internet, raking in a staggering $4.9 billion dollars annually. With such statistics, it is not surprising that 25% of all daily search engine requests are for pornographic material (Ropelato, 2012). As the Internet has expanded to mobile technology, so has sexually explicit material. In 2012, 45.3% of cell phone owners in the United States owned smart phones, with 85% of adults 18 to 29 years of age using the m obile web function on their cell phones (U.S. Census, 2012). In addition, 30 million people reported using their smart phones to watch videos online (Nielsen, 2011). Furthermore, Pew Research revealed that 63% of college undergraduates use the Internet on their cell phones (Smith, Rainie, & Zickuhr, 2011). A recent Hack College survey administered to a sample of college students via Facebook demonstrated that nearly a quarter of the sample population reported using a cell phone to access pornography. Althou gh this survey has issues with its validity and reliability, it stands to reason that this is an issue (Hack College, 2011). As with television, it is important to di scover what lasting effects the possible
40 exposure to sexually explicit Internet materi al and its effect on their sexual health attitudes and behaviors. Sex Education and the Internet Cooper (1998) suggested that teens utilize the Internet for sex information because it is accessible, affordable, and perhaps, most important, it is anonymo us. If adolescents are deriving even part of their sexual health information from the Internet, it is important to evaluate its content, as well as how easily adolescents can find accurate sexual health information. Smith, Gertz, Alvarez and Lurie (2000) c onducted a content analysis in which they assessed the makeup of websites with sex education information, as well as the extent to which students were able to find information that addressed their sexual health questions. Using the key words sexual health, sex education, sexual intercourse, teen sex and sex advice for teens, the researchers retrieved websites to analyze their content. The websites retrieved were categorized as advertisements, editorial commentaries, sex education pages, personal home pages, news articles, organization position statements, pornography, policy/curriculum statements, professional/educational announcements and other. pornography, 12% were other, and 6% were professional/educational announcements; advertisements and sex education pages each represented 4%, editorial commentaries and personal home pages were each 3%, news articles and policy/curriculum statements were each 2% and organization positi on statement sites were 1%. In terms of information search, the study participants, who were college students between 18 21 years of age, were given specific sexual health questions to answer. On average,
41 participants found correct answers to the questions after four minutes of searching (Smith et al., 2000). While the Internet can provide adolescents with a vast amount of health information, as Smith et al., (2000) found, it is important for practitioners and researchers to realize that when searching for sexual health information, adolescents are likely to be led away from the correct information by the wrong type of content or by the amount of time it can take to locate the correct answers to their questions. Sexually Explicit Websites: Prevalence and E ffects As the previous study showed, sexually explicit websites proliferate on the Internet (Smith et al., 2000). In order to address this aspect of new media, Braun Courville and Rojas (2009) examined the effect of sexually explicit websites on adolescen Courville and Rojas (2009) study was a cross sectional survey conducted with more than 400 adolescents, assessing their Internet access, sexual behaviors, sexually permissive attitudes and their exposure to sex ually explicit websites. Among study respondents, 96% of participants reported having Internet access, and 55.4% of these participants reported any exposure to sexually explicit websites. In terms of gender, 86% of males and 50% of females reported that th ey had ever been to a sexually explicit website. Of the 55% who had been exposed to a sexually explicit website, 70% reported infrequent exposure and 30% reported regular exposure over the three months prior to the study. In terms of motivation, 50% report ed they had visited sexually explicit sites because they were curious, 46% reported they had visited by accident, and 17% reported that they were seeking information. The adolescents who did not visit such sites reported either that
42 they were either not in terested in such sites or could not explain why they chose not to visit the sites. In relation to the effects exposure to sexually explicit websites can have on interesting concl usions. Braun Courville and Rojas (2009) found that those who were exposed to sexually explicit websites were more likely to report engaging in high risk sexual behaviors, including having multiple partners and having used alcohol or substances at the time of their last sexual encounter. However, the research found no statistically significant connection between exposure to sexually explicit websites and sexually transmitted infection history, condom use or early initiation of sex. In terms of sexually perm issive attitudes, adolescents who had visited sexually explicit websites were more likely to have sexually permissive attitudes. This was found to reflect a dose the more sexually permissive his or her attitudes. As mentioned, this study was cross sectional, and researchers stressed the need for a longitudinal study in drawing further conclusions. Luder, Pittet, Berchtold, Akre, Michaud, and Suris (2011) also examined the association between exposure to explicit web content and adolescent behavior. The researchers conducted a study using data from a nationally representative cross sectional survey of 7,529 participants between the ages of 16 was to examine the possibility of a relationship between exposure to online pornography and sexual behaviors in their sample. The researchers divided the participants into specific groups based on their exposure to online pornography. Males were separated
4 3 int o three groups: voluntary exposure (29%), unintentional exposure (47%) and no exposure (24%). In comparison to males, 35% of females reported unwanted exposure, and only 1.4 % reported deliberate exposure; the remaining 64% of females reported no exposure to online pornographic content. The study found that within the sample, online pornography exposure was not associated with risky sexual behaviors except for participating in unprotected sex for males. The analysis found that males who were exposed to onl ine pornography had a significantly greater likelihood of not having used a condom at last intercourse (Luder et al., 2011). In research conducted by Peter and Valkenburg (2008), the viewing of sexually explicit web content was shown to be associated with a change in sexual health beliefs. The study examined the relationship between exposure to sexually explicit web content between the ages of 13 to 20 in the Netherlands and w as conducted through an online survey. There were several noteworthy findings from this examination. In terms of exposure, males were more likely than females to be exposed to sexually explicit material on the Internet, while older survey participants wer e more likely than younger participants to report that they viewed SEM online. In reference to the frequency of reported engagement in the behavior at all. In addition, 19% of survey respondents between the ages of 19 to 20 reported viewing sexually explicit material on the Internet "once a week."
44 One type of sexual health belief the study investigated was sexual uncertainty reported by the respondents. Sexual uncertainty was operationally defined as agreeing uncertainty is important in terms of behaviors because the more sexually unc ertain an individual is, the weaker their sexual health attitudes may be, thereby suggesting a lower possibility of strong beliefs or attitudes tied with healthy sex practices. This type of uncertainty was reported more often by males than females and by y ounger participants more often than older participants. The researchers also examined beliefs about uncommitted sexual exploration. This variable was operationalized as agreement that Twenty seven percent of the male participants agreed with this statement, while only 13% of females did so. Younger participants rated uncommitted sexual exploration more favorably than did older participants (Peter & Valkenburg, 2008). Of s viewing of sexually explicit material, the more sexually uncertain they were. Moreover, the higher the exposure to SEM, the greater the association with positive attitudes toward u ncommitted sexual exploration (Peter & Valkenburg, 2008). In further examination of the possible connection between sexually explicit material and sexual health behaviors, Goodson, McCormick and Evans (2001) completed a study examining the relationship be tween exposure to sexually explicit crux of the study was the actual search behavior of the participants when seeking out sexually explicit web content. The study was conducted through a questionnaire
45 administered to a little more than 500 undergraduate college students at one university. The sample was skewed toward females (62% of respondents). The mean age of the sample respondents was 25. The researchers noted that the sample was unique because of its high number of Hispanic respondents, 42% of all participants. Ninety percent of respondents reported that they used the Internet; however, 73% noted they did so less than once a week. Perhaps a sign of the time during which this study was conducted, 2001, only 4% of respondents reported that they used the Internet daily (Goodson et al., 2001). When examining the use of the Internet to obtain sexual material, the researchers found that 56% of the sample reported they ha d never used the Internet to accessing it. The researchers found that females were signifi cantly less likely to have with a group of people (Goodson et al., 2001). The researchers also examined the reasons for seeking out sexually explicit web content. The most frequent reason participants reported for accessing sexually explicit content was curiosity (27%), followed by for sexual arousal (19%) and enhancing their sex l ives with their partner (13%). Respondents who said they used sexually explicit web content for the first two reasons were more likely to be males than females. The study did not connect the online behaviors of the students to their offline sexual health
46 b ehaviors (Goodson et al., 2001). However, other researchers have attempted to do just that. Research conducted by Morgan (2011) revealed that viewing sexually explicit material was connected to an increased number of sexual partners as well as other sexua l health behaviors. The study examined information obtained through an online survey of 782 heterosexual college students with a mean age of 20. The study examined the effects of SEM exposure through experiences with sexually explicit material, sexual beha viors and preferences and sexual and relationship satisfaction. There were several noteworthy results from the analyses. First, 58% of male participants and 7% of females reported that they used sexually explicit materials once every week or more. Moreove r, on average, the males in the study reported they used such material once a week, while the females reported they used it once per year. In addition, males were more likely to view SEM alone than with partners, while females were more likely to view SEM with a partner they were dating. In addition, 92% of men and 50% of women in the study reported that they had ever accessed sexually explicit material in their lifetime (Morgan, 2011). In terms of a connection between SEM and sexual health behaviors, the researcher found that study participants who reported frequently viewing SEM also reported having more casual sex partners. Further, SEM viewing frequency was negatively associated with sexual and relationship satisfaction for male respondents. For number of sexual partners, increased viewing of diverse types of SEM was correlated with having more sexual partners and more casual partners. Types included
47 in the study were online pictures or videos, magazines, books, telephone hotlines, purchased videos, and so on (Morgan, 2011). While sexual content in media has continued to increase, there has also been a growing acceptance of pornography by young adults. Carroll, Padilla Walker, Nelson, Olson, Barry, and Madsen (2008) conducted research investigating the a cceptance and use of pornography among college students in the United States. Survey results showed that 87% of males reported pornography use in comparison to 31% of females. Further, 49% of female respondents and 67% of male respondents agreed that the u se researchers found that while nearly one fifth of male respondents did not believe that pornography use was acceptable, they still reported using it (Carroll et al., 2008). use, the researchers found that the more male participants reported acceptance and use of pornography, the more they reported accepting premarital sex and casual sex behaviors ( Carroll et al., 2008). Pornography as a Public Health Issue Public health advocates have long viewed the growing acceptance of pornography as a public health issue. Perrin, Madanat, Barnes, Carolan, Clark, Ivins, Tuttle, Vogeler, and Williams (2008) argue d that pornography use should be framed as an adult store or renting explicit videos are now able to download pornography with the rrin, et al. (2008) wrote that this is a public health issue because of the connection between Internet pornography use and addiction,
48 which they urge could lead to sexual aggression and sexual risk behaviors, such as promiscuity. Furthermore, a recent Cen pornography industry eroticizes unsafe sex and puts people in direct contact with each other across the globe. There is no connection to safe sex messages or testing A Public Health Approach, 201 0, p.15). Two content analyses published in the last decade further support this idea. Gorman, Monk Turner and Fish (2010) conducted a content analysis of free adult websites paying special attention to portrayals of the acts presented. The researchers fou nd that in terms of the display of bodies, females were more likely to be exposed than males, with the most common theme being domination. This theme was present in more than a third of the sample, with the male character being dominant over the female. Th e researchers found that submission was the most frequent act within the sample of videos (47% of the sample), with the female character being in the submissive role to the male. In addition, the researchers found that 49% of the videos presented a female character who was eager or willing to participate in any act proposed to her. In reference to sexual health, only one video in the sample depicted condom use (Gorman et al., 2010). The second content analysis, conducted by Grudzen, Elliott, Kerndt, Schust er, Brook and Gelberg (2009), investigated condom use in adult films. The researchers reviewed adult entertainment DVDs that were available to rent on the Internet and compared homosexual films to heterosexual films. Heterosexual films were less likely to present safe sex practices than homosexual films. For instance, 7% of heterosexual
49 scenes and 48% of homosexual scenes depicted condom use for penile sexual acts. Further, only 3% of scenes depicting penile vaginal intercourse portrayed condom use. In addi tion, 78% of homosexual scenes versus 10% of heterosexual scenes depicted condom use during anal sex. Neither sample showed condom use during oral sex. The researchers suggested that these trends could influence pornography viewers to devalue safe sex and condom use and reasoned that if adult performers were to adopt condom use in their scenes, it could lead to condom use becoming a normative behavior among audiences (Grudzen et al., 2009). However, a 2011 article published in The New York Times addressed why it may oppose any new regulations because they say that sales drop when performers use 1, pg. A18). This is relevant because the lack of contraception use in pornography may lead viewers to develop real life models of sexual behavior that also do not include contraception use. Hypotheses Through application of the Social Cognitive Theory a nd in consideration of previous research in the subject area, this study will address the following hypotheses: Hypothesis 1 Greater exposure to sexually explicit material on the Internet will negatively affect the sexual health behaviors of college males. (a). Exposure to sexually explicit material on the Internet will be associated with decreased condom use. (b.) Exposure to sexually explicit material on the Internet will be associated with decreased partner
50 communication. (c) Exposure to sexually explici t material on the Internet will be associated with increased risky sexual health behaviors. Hypothesis 2 negative attitude toward using condoms.
51 CHAPTER 3 METHODS The hypo theses were examined using an online survey administered to college males; whenever possible, questions were based on surveys used in previous research. Data Collection Sample Population The population for the study was college males attending the Univers ity of Florida in Gainesville, Fla. While a sizable body of research has investigated the effect of SEIM on adolescents, a review of existing literature revealed a lack of investigation into the effects of sexually explicit Internet material exposure on yo ung adult males in the United States. Moreover, Peter and Valkenburg (2011) found a significant relationship between viewing SEIM and engaging in sexual risk behaviors within the Dutch adult male portion of the study population, while the adolescent portio n had no such relationship between SEIM use and sexual risk behaviors. As a result, the current study investigated whether this relationship also exists within a young adult male population in the United States. Further supporting the selection of college males for the study was research conducted by Buzzell in 2005. In a study investigating the characteristics of those using pornography, Buzzell (2005) analyzed data from the General Social Survey. The data showed that users of sexually explicit Internet m aterial were most commonly male, between 18 25, single, and had completed at least high school (Buzzell, 2005). That demographic group coincides with characteristics of the sample population used in this study: males enrolled in undergraduate college cours es.
52 Sample Recruitment Upon receiving approval from the University of Florida Institutional Review Board, participants were recruited from five undergraduate courses in the Anthropology and Journalism and Communications departments at the University of F lorida in the Fall Semester of 2012. Incentive was given to participants who completed the survey in the form of extra credit for the course in which they were recruited. The extra credit amount ceed one percent of the opportunity, females enrolled in the courses were also given the opportunity to respond to the survey. In addition, due to the sensitive nature of th e topic, male and female students were offered the opportunity to participate in a different study, unrelated to sexual behavior, as a way to earn the extra credit. Furthermore, to ensure that students were able to earn extra credit without participating in a research study, professors were to offer their students a non research based extra credit opportunity in the form of in class discussion participation, written commentary on assigned media content, watching and discussing the presidential debates, and specific research projects, to name a few. No student was required to participate in any form of extra credit activity. Professors who agreed to allow their students to participate in the extra credit opportunity were given an approved script with a bri ef overview of both studies (this one and the alternate) and whom to contact if the students were interested in participating. The scripts were distributed to students via email and online course websites. At that time, students who were interested contact ed the principal investigator to acquire the link to the Qualtrics survey. Upon accessing the survey link, students were first presented with an informed consent slide providing them with a brief overview of the
53 study and their rights should they choose to participate. If participants consented, the survey then loaded. In order to provide anonymity to participants, survey respondents were emailed a three digit ID code, along with the link to the survey to be completed at a time and location of their choos ing. At the close of the survey, professors were emailed a list of their students who had participated in either study on a combined list to ensure students could not be connected to this study over the other or vice versa. This procedure was followed bec ause the Institutional Review Board felt the possibility of embarrassing. Instrument The study used a 59 question online survey to obtain information about college xposure to sexually explicit Internet material and its relationship to their sexual health beliefs and behaviors. In the past, studies that have examined issues similar to this topic have utilized online surveys (Peter & Valkenburg, 2008; Morgan, 2011; Car roll, Padilla Walker, Nelson, Olson, Barry, & Madsen, 2008; Olmstead, Pasley & Fincham, 2013; GatorWell, 2009). Research conducted by Mustanski (2001) suggested that Internet based surveys are most appropriate when investigating a sensitive topic like sexu al health matters because they provide a form of anonymity that tends to lower the inhibitions of respondents. This appears to hold true when applied to sample populations of young adult males, like those who participated in this study (Morgan, 2011). Res earch has shown that young adult males will complete an online survey even when the survey involves questions of a sensitive nature. Peter and Valkenburg (2008)
54 used an online survey to ask adolescent and young adult participants questions about their expo sure to sexually explicit web materials, as well as their sexual behaviors and beliefs. Morgan (2011) utilized an online survey in which college males responded to questions about pornography use, sexual satisfaction, sexual behaviors and sexual preference s. In addition, Carroll, Padilla Walker, Nelson, Olson, Barry, and Madsen (2008) asked college participants to respond to an online survey questions inquiring Similarly, Olms tead, Pasley and Fincham (2013) obtained information from college males about their casual sex behavior through an online survey. Most closely tied with the intended sample population and demonstrating the success of online surveys for assessing college ma 2009 GatorWell Sexual Health Student Survey. In the survey, University of Florida students responded online to questions about their knowledge and experience with sexually transmitted infecti ons, condom use, and pornography use with an overall response rate of 33% with no incentive for participation. Operational Definitions In terms of operational definitions, Peter and Valkenburg (2011) defined sexually professionally produced or user generated (audio) visual material on or from the Internet that typically intends to arouse the viewer and depicts sexual activities and (aroused) genitals in unconcealed ways, usually with close ups on oral, anal and vaginal operational definition was applied to the study. Previous research was used to pinpoint key components to use in the definition of sexual risk behavior for this study. Within this previous research, se xual risk behavior
55 was defined as having engaged in oral, anal or vaginal sex with five or more partners in the previous year; having engaged in sex with a partner whose sexual risk history is unknown or ignored; having engaged in anal or vaginal sex witho ut a condom, or in oral sex without a condom or similar protective barrier; and having engaged in sex under the influence of drugs or alcohol (DiIorio, 2011; Smith & Ford, 2010). However, for the purpose of this study, a multi item scale first developed by Dilorio (2011) was adapted to assess sexual risk behaviors. Measures The study examined the relationships among four key measures: frequency of sexually explicit Internet material use, sexual risk behavior, attitudes toward pornography, and attitudes towa rd condom use. Use of SEIM The use of sexually explicit Internet material was investigated based on the self reported frequency of four behaviors in the six months prior to the completion of the survey. Questions were adapted from Peter and Valkenburg (2 011): pictures with clearly exposed genitals; video (clips) with clearly exposed genitals; pictures in which adults are engaging in any sexual behavior including fondling, masturbation, or al sex, penetrative sex; video (clips) in which adults are engaging in any sexual behavior including Survey participants responded using a 7 point scale from never to more than once per day. These four m easures were added to form one scale of Sexually Explicit
56 Internet Material Exposure, with higher scores denoting more frequent exposure to SEIM. Sexual Risk Behaviors Sexual risk behavior was determined by asking participants to respond to the Safe Sex B ehavior Questionnaire developed by Dilorio (2011). The questionnaire included 24 questions to be answered using a 4 point Likert scale from 1 (Never) to 4 (Always). Because several of the sexual health behavior assessment questions were repetitive or appli sexual risk behaviors, the questionnaire was reduced to 16 questions. The questionnaire included items aimed at assessing contraception use, history, and their willingness to communicate about sexual health with their sexual partners. frequently they insist on condom use during sex ual intercourse. Questions included whether condoms were used during oral sex, during vaginal sex and during anal sex. In example: tercourse, I carry a condom with me. 1 (Never) 2 (Sometimes) 3(Often)
57 Participants also were asked how frequently they are willing to engage in sex without a condom if they are caught up in the moment: ent, I have sexual intercourse without using a condom. 1 (Never) 2 (Sometimes) 3(Often) questions focused on substance use, protective measures, and whom they choose to have sex with: 1 (Never) 2 (Sometimes) 3(Often) 1 (Never) 2 (Sometimes) 3(Often) history. 1 (Never) 2 (Sometimes) 3(Often) discuss sexual histories and communication with their partners. For example: he topic of safer sex with my potential sexual partner. 1 (Never) 2 (Sometimes ) 3(Often)
58 Reliability analysis was used to determine which questions could be combined into separate scales to establish sexual risk behaviors. Within this analysi s process, inter item correlations were utilized to determine which items represented a level of among themselves, and thus were measuring the same concept, were broken d own into separate scales. Reliability analysis was then re run for these individual scales. From here, item total statistics were performed on the newly established scales. When question was dropped from the scale. Bivariate analysis was conducted to assess which questions could be correlated at the 0.01 significance level before any questions were dropped from the scales. These analyses led to the creation of the following three scales: I insist on condom use when I have sexual intercourse. I stop foreplay long enough to put on a condom (or for my partner to put on a condom). If I know an encounter may lead to sexual intercourse, I car ry a condom with me. I ask potential sexual partners about their sexual histories. I insist on examining my sexual partner for sores, cuts or abrasions in the genital area. I ask my potential sexu al partners about a history of IV drug use. I initiate the topic of safer sex with my potential sexual partner.
59 I engage in anal intercourse without using a condom. I use cocaine or other dr ugs prior to or during sexual intercourse. I engage in sexual intercourse on a first date. I engage in anal intercourse. I drink alcohol prior to or during sexual intercourse. Four questions that were not shown to fit reliably with other scale items were dropped: I engage in oral sex without using protective barriers such as a condom or rubber dam. If swept away in the passion of the moment, I have sexual intercourse without using a condom. I abstain from sexual intercourse when I do not know my partne I avoid sexual intercourse when I have sores or irritation in my genital area. The final questions in each scale were added and then divided by the number of items to achieve one final score, with higher scores on each scale denoting riskier sexual health behaviors. Attitudes Toward Pornography responses to the Pornography Attitudes Scale developed by Evans DeCicco and Cowan (2001). This scale contains 13 questi ons to be answered using a 5 point Likert scale from 1(strongly disagree) to 5(strongly agree). The scale includes questions that assess whether respondents have negative or positive attitudes toward pornography (Evans DeCicco & Cowan, 2001).
60 Negative att itude items included statements such as: Contrastingly, positive attitude items included the following statements: Reliability analysis was used to determine which questions could be combined into separate scales to establish sexual risk behaviors. Within this analysis process, inter item correlations were utilized to determine which i tems represented a level of internal consistency for separate scales for the sample data. Questions that had higher were collected into separate scales. Reliability analysis was then re run for these individual scales. Item total correlations were performed on the newly established dropped from the scale. Bivariate analysis was conducted to asse ss which questions were correlated at the 0.01 significance level before any questions were dropped from the scales. These analyses led to the creation of the following scales. Pornography te aches new sexual techniques. Pornography is educational. Pornography releases sexual tension. Viewing pornography is a harmless activity.
61 Pornography degrades women. Pornography degrades men. F our questions were omitted due to their lack of correlation with other scale items: Pornography is stimulating and exciting. Pornography gives women false expectations about the opposite sex. Pornography gives men false expectations about the opposite sex . Pornography leads to sexual addiction. Questions were reverse coded as necessary, and responses were added to create each scale. A high score on the Pornography as Positive scale was interpreted as a more positive attitude toward pornography, while a hi gh score on the Pornography as Degrading scale indicated more negative attitudes toward pornography. Attitudes Toward Condom Use original questions in The Brief Condom Attitudes Sc ale developed by Hill, Amick, and Sanders (2011) as a brief assessment for condom use among heterosexual college students. One question was omitted due to its confusing wording and interest in other ple make use of the condom as an erotic part to foreplay. Respondents answered the questions using a Likert scale attitudes toward condom use in regard to four areas:
62 Item s relating to condoms interrupting sexual activity included the following statements: Items relating to condom use being erotic included the following statements: Items expressing negative attitudes toward condom use included the following statements: e.g. no wet spot on the bed) makes them more Items related to condoms providing protection included the following statements: After data were collected, reliability analyses were performed on the questions. when five questions were omitted that did not have high inter item correlations with the
63 other questions and did not have high enough correlations with each other to be used for separate scales. Those items were: Putting a condom on an erect penis (hard on) can be a real sexual turn on. The condom is a highly satisfactory form of STD prevention. I see the use of a condom as adding to the excitement of foreplay if the partner helps the other put it in place. Condoms seem safer to me than any other form of contracepti on. I think condoms look ridiculous. Items were added together to create one condom use attitudes scale; the higher the respondents scored, the more positive their attitude toward condoms. Using a cond om requires taking time out of foreplay, which interrupts the pleasure of sex. Condoms are pleasant to use. The condom is a highly satisfactory form of contraception. Having to stop to put on a condom takes all the romance out of sex. The neatness of co ndoms (eg. No wet spot on the bed) makes them more attractive to use. The use of a condom is an interruption to foreplay. Condoms are inconvenient. I think pro per use of a condom can enhance sexual pleasure. Condoms are uncomfortable for both parties.
64 Demographics Respondents were asked to report information about several key demographic characteristics , including their age, race, sexual orientation and relationship status. Respondents were also asked how many oral, vaginal and anal sex partners they had had in the year prior to completion of the survey, the age at which they first engaged in these behav iors, and the age at which they first were exposed to pornography. Data Analysis All data analysis was conducted using SPSS. Before proceeding to Linear Regression, One Way ANOVA Means Tests were run for all scales to establish whether demographic variab les such as age, race and sexual orientation would skew or mask results. If a variable was found to be a significant predictor for any scale, a dummy variable was created for the variable to be used in Linear Regression calculations. Afterward, Linear Regr ession calculations were run using each of the scales to assess each of the hypotheses, and post hoc analyses were performed.
65 CHAPTER 4 RESULTS Sample Characteristics Of the 85 respondents, ages ranged from 18 to 22 years or older. Mean and median age c ould not be calculated precisely because respondents were allowed to indicate that they were 22 or older; however, using 22 as the maximum age puts the mean age of respondents at 20 years old. The modal age response (32.9%) was 20 years old. In terms of ra ce, the majority of respondents were white, non Hispanic (58.8%), and the majority of respondents (85.9%) identified their sexual orientation as heterosexual. For relationship status, most respondents identified as being single (68%). (See Table 4 1.) The respondents were asked how many sexual partners they had had in the year prior to completing the survey and at what age they first had engaged in oral, vaginal and anal sex. In terms of numbers of sex partners in the past year, the most common response wa s one partner for both oral sex (34.1%) and vaginal sex (37.6%). In terms of age at first engaging in oral sex, the majority of respondents reported that they first engaged in this behavior between ages 15 and 17 (50.6%); this was also the most common age for first engaging in vaginal sex (41.2%). The majority of respondents reported that they had never engaged in anal sex (69.4%), and more than three quarters had had no anal sex partners in the past year (78.8%). Respondents also were asked at what age th ey were first exposed to pornography. Only 1.2 % reported never being exposed to pornography, or being exposed at age 18 or older. The largest number of respondents reported first exposure to pornography between ages 11 and 12 (37.6%), followed closely by between 13 15
66 (34.1%). Fewer reported being exposed at age 10 or younger (17.6%) or between the ages of 16 and 18 (8.2%). (See Table 4 2.) General Responses for Independent and Dependent Variables Use of SEIM. net material was assessed based on the viewing of pictures and video depicting nude images of adults or adults having sex. In the six months prior to the survey, 83.5% of respondents had viewed pictures of adults with clearly exposed genitals; most commonl y, the men reported viewing such images once per week. Viewing of videos of adults with clearly exposed genitals was reported by 89.4% of respondents, with the most common response being viewing the videos two to six times per week. In terms of viewing pho tos of adults having sex, 75.3% of respondents reported viewing the material in the past six months; about one in five reported viewing such images once per week, and the same percentage (21.2%) viewed sex photos two to six times per week. For viewing vide os of adults having sex, 90.6% of respondents reported viewing the material in the past six months, with the most common response being viewing these types of videos two to six times per week. Overall, nearly 70% of the respondents watched sex videos at le ast once a week. (See Table 4 3.) Use of SEIM scale. Use of sexually explicit Internet material was assessed based on the responses to the following four questions, as reported in Chapter 3 : In the past 6 months, how often have you intentionally looked a t pictures with clearly exposed genitals? In the past 6 months, how often have you intentionally looked at video (clips) with clearly exposed genitals?
67 In the past 6 months, how often have you intentionally looked at pictures in which adults are engaging in any sexual behavior including fondling, masturbation, oral sex, penetrative sex? In the past 6 months, how often have you intentionally looked at video (clips) in which adults are engaging in any sexual behavior including fondling, masturbation, oral se x, penetrative sex? Responses to the four questions were added to create a sum on the scale and then divided by the number of questions, four. Participants responded to each item using a 7 point scale, from 1 (never) to 7 (more than once per day). The me an of the scale was 3.724 with a standard deviation of 1.353 and a range of 1 to 7, illustrating that the majority of participants fell within the category of accessing SEIM in some form about once per month to once per week. In terms of race, whites repor ted more frequent use than the average, once per week, [M = 3.965, SD = 1.434], while blacks reported less frequent use, once in the past six months to one time per month, [M = 2.214, SD = 1.194]. SHB partner communication scale. The partner communication aspect of sexual health behavior was assessed based on responses to the following four questions, as reported in Chapter 3 : I ask potential sexual partners about their sexual histories. I insist on examining my sexual partner for sores, cuts or abrasions i n the genital area. I ask my potential sexual partners about a history of IV drug use. I initiate the topic of safer sex with my potential sexual partner. Responses to the four questions were summed and then divided by the number of questions, four. Pa rticipants responded to each item using a 4 point scale, from 1(always communicating prior to sex) to 4 (never communicating prior to sex). The
68 mean of the scale was 2.9639 with a standard deviation of 0.76323 and range of 1 to 4. These findings demonstrat e that the majority of the sample reported often or sometimes communicating with their partner about safer sex before having sex. Respondents in the Other race category reported less partner communication than remaining racial categories, with the majorit y falling between the categories of sometimes and never communicating with their partners, [M = 3.341, SD = .683]. SHB condom use scale. Condom use was assessed based on the responses to the following three questions, as reported in Chapter 3 : I insist o n condom use when I have sexual intercourse. I stop foreplay long enough to put on a condom (or for my partner to put on a condom). If I know an encounter may lead to sexual intercourse, I carry a condom with me. Responses to the three questions were add ed to create a total for the scale and then divided by the number of questions, three. Participants responded to each item using a 4 point scale, from 1 (always using or planning to use condoms) to 4 (never planning on using condoms). The mean of the scale was 1.873, with a standard deviation of 0.928 and range of 1 to 4, illustrating that most respondents reported frequent use or planned use of condom s. In terms of condom use, the o ther racial category reported riskier behaviors, on average, by often or so metimes planning to use condoms, [M = 2.697, SD = 1.286]. Risky SHB scale. The risky sexual health behavior scale contained the following five questions, as explained in Chapter 3 : I engage in anal intercourse without using a condom. I use cocaine or other drugs prior to or during sexual intercourse. I engage in sexual intercourse on a first date.
69 I engage in anal intercourse. I drink alcohol prior to or during sexual intercourse. Responses to the questions were added together and then divided by the num ber of questions, five. With this scale, lower scores represented less risky behaviors (1=never engaging in these risky behaviors), and higher scores represented riskier behaviors (4=always engaging in these risky behaviors). The mean of the scale was 1.46 83 with a standard deviation of 0.46954 and range of 1 to 4, demonstrating that the majority of participants reported infrequently engaging in risky sexual health be haviors. In terms of race, the o ther racial category reported slightly less frequent engage ment in risky sexual health behaviors, never to sometimes, [M = 1.222, SD = .273]. Attitudes toward pornography: pornography as positive scale. Four questions made up the positive attitudes toward pornography scale: Pornography teaches new sexual technique s. Pornography is educational. Pornography releases sexual tension. Viewing pornography is a harmless activity. The items were added together and then divided by the number of questions, four. Participants responded to each item using a 5 point scale, fr om 1(strong disagreement that pornography is positive) to 5(strong agreement that pornography is positive). With this scale, lower scores reflected more negative attitudes toward pornography, while higher scores represented more positive attitudes toward p ornography. The scale mean was 3.5529, with a standard deviation of 0.70404 and range of 1.5 to 5, demonstrating that the majority of respondents reported relatively positive attitudes toward pornography. In terms of race, Hispanic respondents reported sli ghtly more positive attitudes toward pornography, [M = 3.706, SD = .607], while black
70 respondents reported slightly less positive attitudes toward pornography, [M = 3.179, SD = 1.087]. Attitudes toward pornography: pornography as degrading scale. The porno graphy as degrading scale involved two questions: Pornography degrades women. Pornography degrades men. The question responses were summed and then divided by the number of questions, two. Participants responded to each item using a 5 point scale, from 1 (strong disagreement that pornography is degrading) to 5 (strong agreement that pornography is degrading). Within this scale, lower responses represented disagreement that pornography is degrading, and higher scores represented greater agreement that porn ography is degrading. The scale mean was 3.1012, with a standard deviation of 0.93067 and range of 1 to 5, indicating that the majority of scores fell in the middle of the scale; on average, then, respondents were neutral about the idea of pornography as d egrading. Examining race, the o ther category reported more disagreement with the statements that pornography was degrading, [M = 2.636, SD = .978], while white respondents scored higher in agreement that pornography was degrading, [M = 3.296, SD = .941]. A ttitudes toward condom use: condom use attitudes scale. Twelve questions composed the condom use attitudes scale: Using a condom requires taking time out of foreplay, which interrupts the pleasure of sex. Condoms are pleasant to use. The condom is a highl y satisfactory form of contraception. Having to stop to put on a condom takes all the romance out of sex.
71 The neatness of condoms (e.g. No wet spot on the bed) makes them more attractive to use. The use of a condom is an interruption to foreplay. Condoms are inconvenient. I think proper use of a condom can enhance sexual pleasure. Condoms are uncomfortable for both parties. rtner(s) to use condoms. The items were summed and then divided by 12. Participants responded to each item using a 5 point scale, from 1 (strong negative attitude toward condoms) to 5 (strong positive attitude toward condoms).Within this scale, higher nu mbers represented more positive attitudes toward condom use, while lower scores represented more negative attitudes toward condom use. The mean was 3.2906, with a standard deviation of 0.67419 and range of 1.25 to 4.67, demonstrating that the majority of r espondents reported relatively neutral attitudes toward condom use, with a slight tendency towa rd the positive. Those in the o ther racial category scored lower, reporting more negative attitudes toward condom use, [M = 2.825, SD = .780], while Hispanic res pondents scored higher, reporting slightly more positive attitudes toward condom use than those in remaining racial categories, [M = 3.619, SD = .393]. (See Tables 4 4 and 4 5.)
72 Tests of Hypotheses Hypothesis 1 Hypothesis 1: Greater exposure to sexuall y explicit Internet material will be positively correlated with riskier sexual health behaviors and attitudes among college males. (a) Exposure to sexually explicit material on the Internet will be associated with less frequent reported condom use. (b) E xposure to sexually explicit material on the Internet will be associated with decreased partner communication. (c) Exposure to sexually explicit material on the Internet will be associated with increased risky sexual health behaviors. Hypothesis 1a was that more frequent exposure to sexually explicit material on the Internet would be associated with less frequent reported condom use. To test this hypothesis, regression analysis was performed, with the SEIM scale as the independent variable and the SHB Co ndom Use scale as the dependent variable. With no control variables in the model, there was no statistically significant relationship between exposure to SEIM and condom use. However, one way ANOVAs had revealed that both condom use and exposure to SEIM va ried significantly by race, [condom use: F (3, 80) = 3.679, p = .015; SEIM exposure: F (3, 81) = 3.915, p = .012.] Controlling for race produced a significant relationship between SEIM exposure and condom use; further examination of the data revealed that this correlation was si gnificant only among the other race group. Hypothesis 1b was that greater exposure to sexually explicit Internet material would be associated with decreased partner communication about sex. Multiple regression analysis was used to t est the hypothesis, with SEIM as the independent
73 variable and the SHB Partner Communication Scale as the dependent variable. Controlling for race and sexual orientation, SEIM exposure was not a significant predictor of partner communication about sex. Hypo thesis 1c was that exposure to sexually explicit material on the Internet would be associated with increased risky sexual health behaviors. The hypothesis was tested using linear regression, with SEIM exposure as the independent variable and the Risky SHB scale as the dependent variable. With no control variables included, analysis revealed that exposure to SEIM was a statistically significant predictor of increased risky sexual health behaviors. When controlling for race, the relationship between SEIM expo sure and risky sexual health behaviors was attenuated, but remained a significant predictor of risky sexual behavior for the o ther race category. Hypothesis 1a was partially supported, and 1c was supported, while Hypothesis 1b was rejected, leading to par tial support for Hypothesis 1. (See Table 4 6.) Hypothesis 2 Hypothesis 2: related to their attitudes toward using condoms. The hypothesis was tested using linear regression, with the Positiv e Attitude Toward Pornography scale as the independent variable and the Condom Use Attitudes scale as the dependent variable. With no control variables in the model, there was no d pornography and their attitudes toward using condoms. However, a one way ANOVA had revealed that condom use attitudes varied significantly by race [ F (3, 72) = 3.376, p = .023.] Controlling for race, regression analysis revealed that a positive attitude toward
74 pornography was a significant predictor of condom use attitudes among black males only. Therefore, Hypothesis 2 was partially supported. (See Table 4 7.) Post Hoc Analyses Post hoc analyses were conducted to further examine the relationships among race, attitudes toward pornography and risky sexual health behaviors. A linear regression analysis was performed with the Pornography as Positive scale as the independent variable and the Risky SHB scale as the dependent variable. The results revealed a s tatistically significant positive relationship between attitudes toward pornography and engaging in sexual risk behaviors. In addition, linear regression revealed that attitude toward pornography was a statistically significant predictor of SEIM use, with out controlling for race. Because one way ANOVA had revealed that responses on the SEIM use scale varied by race [ F (3, 81) = 3.915, p = .012], with white males reporting significantly more SEIM use, the regression analysis was re run controlling for race. A statistically significant relationship between attitude toward pornography and SEIM use was found for white males only. Further, linear regression was conducted to examine whether positive attitudes toward pornography and SEIM use would be significant as predictors for risky sexual health behaviors. Without any control variables, a statistically significant relationship was found, demonstrating that a positive attitude toward pornography was a predictor for risky sexual health behaviors. When race was added to the model, the relationship was attenuated, but remained significant. (See Tables 4 7 and 4 8.) The significance of the hypotheses tests and post hoc findings will be discussed in Chapter 5.
75 Table 4 1. Demographic characteristics of sample popul ation. Characteristic n % Age 18 16 18.8 19 13 15.3 20 28 32.9 21 17 20.0 22 or older 11 12.9 Ethnicity or race White, non Hispanic 50 58.8 Black, non Hispanic 7 8.2 Hispanic or Latino/a 17 20.0 Asian or Pacific Islander* 2 2.4 American Indian, Alaska Native or Native Hawaiian* 1 1.2 Biracial or multiracial* 6 7.1 Other* 2 2.4 Sexual orientation Straight 73 85.9 Gay or lesbian 9 10.6 Bisexual 2 2.4 Other 1 1.2 Relationship status Single 58 68.2 In a relationship, not married 27 31.8 Married 0 0.0 Age at first exposure to pornography Never 1 1.2 Age 10 or younger 15 1 7.6 Between 11 and 12 32 37.6 Between 13 and 15 29 34.1 Between 16 and 18 7 8.2 Age 18 or older 1 1.2 *The other race variable used in analyses was comprised of these race categories.
76 Table 4 2. Sexual activity by age. Oral sex Vaginal sex Anal sex n % n % n % Number of partners 0 18 21.2 29 34.1 67 78.8 1 29 34.1 32 37.6 10 11.8 2 5 26 30.6 15 17.6 8 9.4 6 10 11 12.9 7 8.2 0 0.0 11 20 1 1.2 2 2.4 0 0.0 Age at first sexual inter action Never 15 17.6 21 24.7 59 69.4 <12 2 2.4 0 0.0 0 0.0 13 14 7 8.2 3 3.5 0 0.0 15 17 43 50.6 35 41.2 10 11.8 18 20 17 20.0 24 28.2 12 14.1 >21 1 1.2 2 2.4 4 4.7
77 Table 4 3. Use of SEIM. Nude images N ude video Sex images Sex video n % n % n % n % Frequency of use Never 14 16.5 9 10.6 21 24.7 8 9.4 Once 8 9.4 5 5.9 8 9.4 5 5.9 One time per month 14 16.5 12 14.1 14 16.5 13 15.3 One time per week 22 25.9 19 22.4 18 21.2 18 21.2 2 6 times per week 20 23.5 32 37.6 18 21.2 33 38.8 Once per day 6 7.1 6 7.1 5 5.9 6 7.1 More than once per day 1 1.2 2 2.4 1 1.2 2 2.4
78 Table 4 4. Descriptive statistics for scales. Scale M SD Sexual risk behavior Condom use 1.873 .928 Partner communication 2.964 .763 Risky sexual health behavior 1.468 .470 Attitudes toward pornography Pornography as positive 3.552 .704 Pornography as degrading 3.101 .931 Attitudes toward condom use Condom use attitudes 3.291 .674 SEIM use scale SEIM use 3.724 1.353
79 Table 4 5. Descriptive statistics for scales by race. Scale White Black Hispanic Other M SD M SD M SD M SD Sexual risk behavior Condom use* 1. 727 .773 1.809 1.103 1.792 .806 1.286 Partner communication 2.857 .794 3.000 .736 3.016 .703 3.341 .683 Risky sexual health 1.544 .531 1.343 .360 1.425 .334 1.222 .273 Attitudes toward pornography Pornography as positive 3.620 .602 3.179 1.087 3.706 .607 3.250 .908 Pornography as degrading 3.296 .941 2.714 .636 3.000 .866 .978 Attitudes toward condoms* 3.259 .587 3.600 .925 3.619 .393 .780 SEIM use scale** 3.965 1.434 1.194 3.559 .899 3.841 1.097 *p<.05 **p<.01
80 Table 4 6. Linear regression: SEIM as a predicto r of sexual risk behaviors. SEIM Use B SE B B CI Sexual health behaviors Condom use .035 .058 .067 [ .150, .081] Partner communication .124 .123 .065 .220 [ .006, .253] Risky sexual health behaviors .012** .120 .046 .277 [.027, .212] * p <.05 ** p <.01 onship significant only among other racial group.
81 Table 4 7. Linear regression: attitude toward pornography as a predictor of attitudes and behaviors, standardized regression coefficients (Betas). Predictor Regre ssion coefficients Condom attitudes Risky sexual health behavior SEIM use Positive attitude toward pornography .134 .297** .335** Covariates White .008 .195** Black .895* .074 .181 Hispanic .296 .116 Other .270 .159 .142 * p <.05 ** p <.01 Covariates were omitted if they did not contribute to the R squared change.
82 Table 4 8. Linear regression: attitudes toward pornography and SEIM use as a predictor of sexual health behaviors. Risky sexual healt h behaviors B SE B B CI Variable Intercept 3.409** 1.291 [.86, 5.958] Positive pornography attitude .187* .092 .228 [.004, .371] SEIM use .085 .048 .198 [ .011, .182] * p <.05 ** p <.01
83 CHAPTER 5 DISCUSSION Study Findings The findings of this study ind icate that exposure to sexually explicit Internet material is associated with sexual health behaviors such as condom use and risky sexual behaviors such as using drugs or alcohol prior to sex or engaging in sex on a first date; however, the findings sugges t no association with partner communication about sex. Furthermore, having a positive attitude toward pornography appears to be associated with three separate variables of the study: negative attitudes toward condom use, risky sexual health behaviors and S EIM use. A model including positive attitude toward pornography and SEIM use also predicted a significant amount of variance in risky sexual health behaviors. Although causation cannot be determined with this type of cross sectional study, the literature to sexually explicit Internet material may contribute to riskier sexual health behaviors and attitudes. This relationship will be discussed further later in this chapter, as well as how race played a significant role in the findings, following discussion of the general characteristics of the study respondents. General Characteristics of the Study Respondents SEIM use and exposure. material was examined by assessing how frequently they reported viewing pornographic photos and videos. The survey revealed high frequencies of use of both photos and videos, most commonly once per month to once per week. Whites reported slightly
84 more fre quent use than the average, about once per week, while blacks reported less frequent use, about once in the past six months to once per month. Previous research has shown that the percentage of college males exposed to pornography was as high as 92%, with 58% viewing sexual content on the Internet at the sample reported never being exposed to pornography a startling increase and perhaps indicative of the increase in acc ess to and use of the Internet in the few years per week; in comparison, 48.3% of males in the current study reported watching pornographic videos more than once per week. Although this study did not investigate the relationship between age of first exposure to pornography and sexual risk behaviors and attitudes, it is worth noting that the majori ty (56.5%) of respondents were first exposed to pornography at or before the age of 12, with 17% of the total sample exposed at age 10 or younger. These statistics are startling on their own, but they are particularly interesting when compared to other rec ent research showing that only 1.8% of college males reported being exposed to pornography at age 10 or younger (Sabina, Wolak and Finklehor, 2008). These statistics could have implications for the sexual health of young males, and indirectly for females, as this may signal that young males are developing a habit and an attitude that is a threat to their sexual health at even younger ages than previously thought. Sexual health risk behavior. Sexual health risk behavior was determined by ponses to three scales, measuring condom use, partner
85 communication about sex and risky sexual health behaviors. The results for these scales revealed a survey population who reported frequent use or planned use of condoms; who sometimes communicates with their partners regarding sexual health issues; and who report infrequently engaging in risky sexual health behaviors. Splitting the sexual health risk behavio r scales by race, males in the o ther racial category reported less frequency of condom use (often or sometimes planning to use condoms) and less partner communication (sometimes or never communicating with their partners). However, they also reported less engagement in risky sexual health behaviors (sometimes to never), a lower score on the scale than those of white, black or Hispanic respondents. These findings were inconsistent with previous research, which has demonstrated that college males frequently engage in high risk behavior like casual sex, sex while under the influence of drugs or alcoho l and an overall belief that the costs of using a condom (such as interruption of foreplay or embarrassment) far outweigh the benefits associated with protection from sexually transmitted infection. However, the finding of frequent use or planned use of co ndoms among college males was consistent with previous condom use research done at the University of Florida, which found that only 32.2% of students reported never using a condom during sex. Although these findings are indicative of the idea that college males do not yet have, or perhaps choose not to use, the skill set to communicate with their partners regarding sexual history and other sexual health issues, the increase in frequent or planned use of condoms, as well as relatively infrequent engagement i n risky sexual health behaviors, are positive notes. However, it should be noted that because these data are self reported, it is not
86 guaranteed that participants are engaging in healthier behavior; they may just be reporting it as a way to comply with a h ealthy social norm. Attitudes toward pornography. pornography were assessed on two scales: the pornography as a positive scale and the pornography as degrading scale. The majority of participants reported positive attitudes toward pornography. In comparison, when responding to questions about pornography as degrading, the majority of participants reported a neutral attitude. Looking at race on the pornography as positive scale, Hispanic males reported slightly more positive attitudes toward pornography, while black males reported less positive attitudes. For the pornography as degrading scale, white respondents scored higher in ag reement and respondents in the o ther racial category reported more disagreement with the statements that pornography was degrading. Knowing that college males had high rates of exposure to SEIM and accessed the material on a regular basis, it may have been assumed that they would also have overwhelmingly positive attitudes toward the materi al. However, this was not the case. These findings were consistent with previous research from Carroll, Padilla Walker, Nelson and Olson (2008), who found that 67% of their sample of U.S. college males reported acceptance of pornography, with the attitude that it is an acceptable toward pornography, 20% reported using it anyway (Carroll, et al., 2008); similarly, the men who participated in the current study reported high us e of pornography, although their attitudes toward pornography were not universally positive.
87 Attitudes toward condom use. An additional aspect of sexual health, scale. T he majority of participants reported relatively neutral attitudes toward condom use with a slight leaning toward the positive. When splitting by race, men in the o ther racial category scored lower on the condom use attitudes assessment, signaling negative attitudes, while Hispanic respondents reported slightly more positive attitudes toward condom use than the average. These findings differed from previous findings using the same scale, developed ound that college males participants reported a positive attitude toward condoms as a means for adequate protection against unwanted pregnancy and sexually transmitted infection, which was similar to findings from Hill, Amick, and Sanders. The researchers proposed that this previously had found to be negative. The current research contributes to the idea that college males are viewing condoms with less negative attitudes. However, it should be noted that these findings, which are neutral with only a slight positive lean, do not suggest enough of a positive attitude toward condoms to ensure a l ink to consistent use. Hypotheses Findings Compared to Previous Research Based on previous research, it was predicted that exposure to sexually explicit Internet material would be negatively correlated with sexual health behaviors among college males wit hin three sectors: condom use, partner communication, and risky
88 partially supported. The predictions for Hypothesis 1 were modeled after findings from Morgan (2011), who f ound that college students who viewed sexually explicit material were more likely to report casual sex behaviors and an increase in partners, two components of risky sexual health behavior. This study produced similar findings, at least in terms of risky s exual health behaviors such as engaging in sex on the first date and decreased condom use. SEIM as a predictor of condom use. The use of sexually explicit Internet material was found to be a statistically significant predictor of condom use, but only f or men in the o ther race category; for these men, more frequent exposure to sexually explicit Internet material was associated with less frequent reported condom use. For white, black and Hispanic males, the relationship was not significant. Although the curr ent study did not ask about condom use at last in tercourse, the finding for the o ther race category may be compared with previous research by Luder, et al. (2011), who found that males who were exposed to online pornography had a significantly greater like lihood of not having used a condom at last intercourse. This relationship between SEIM exposure and condom use has implications for the sexual health of college males in the o ther race category. Knowing that high rates of SEIM exposure already exist, to f ind that condom use may decrease as SEIM use increases is of particular concern; by failing to use condoms consistently, these men are risking their health and wellbeing, as well as that of their partners, particularly when considering the high rates of se xually transmitted infections in the United States.
89 SEIM as a predictor of partner communication. Sexually explicit Internet material use was not found to be a statistically significant predictor of partner communication about sex. However, this may simpl y reflect the fact that there was little variance in the reports about partner communication; the vast majority of men in the study scored 2.9639 on the partner communication scale. College males may simply not engage in partner communication, period, rega rdless of outside factors such as pornography exposure. Dilorio, Dudly, Lehr, and Soet (2000) described partner communication for college males as a complicated balance between self efficacy, communication outcome expectations that is not easily predictable. Taking this previous research into consideration, it is unlikely that the current study would have found a statistically significant relationship for partner communication and SEIM use bec ause predictors such as self efficacy and perceptions of communication with partners were not measured. SEIM as a predictor of risky sexual health behaviors. SEIM use was found to be a statistically significant predictor of increased risky sexual health b ehaviors, as predicted. These risky sexual health behaviors included actions such as engaging in sex on a first date and high risk sexual encounters (consuming drugs or alcohol before sex, engaging in anal sex.) This relationship reinforces connections fou nd by Morgan (2011) that males who reported frequently viewing SEIM also reported having more casual sex partners. Moreover, Carroll, et al. (2008) found that the more males reported use and acceptance of pornography, the more they reported accepting prema rital sex and casual sex behaviors.
90 This relationship is concerning, given that the sample reported such high use of SEIM. With SEIM being a predictor of increased risky sexual health behaviors and college males reporting such a high frequency of use, it is concerning that they may also be or will be engaging in risky sexual health behaviors, putting not only their health but the health of their partners at risk. Attitudes toward pornography as a predictor for attitudes toward condom use. The second hypo would be negatively related to their attitudes toward using condoms. When controlling for race, a positive attitude toward pornography was found to be a significant predictor of less positive cond om use attitudes, but only for black males. This finding was consistent with previous research that found that having positive attitudes toward pornography was related to more frequent engagement in premarital sex and casual sex behaviors (Carroll, et al ., 2008). However, it should be noted that little previous research has examined the relationship between attitudes toward pornography and attitudes toward condom use. Post Hoc analyses. Post hoc analyses were conducted to further examine the relationship s between attitudes toward pornography and sexual health behaviors that the hypotheses did not address. Post hoc analyses revealed three relationships worth noting: sexual risk behavior increased as positive attitudes toward pornography increased; exposur e to SEIM increased as positive attitudes toward pornography increased for white males; and controlling for SEIM exposure, risky sexual health behaviors increased as positive attitudes toward pornography increased; when controlling for race, the relationsh ip was attenuated, but remained significant.
91 These post hoc findings are particularly concerning because the majority of the because the majority of the participants began v iewing pornography at a young age. If boys are viewing pornography at a young age, it stands to reason that they could be developing this positive attitude early in life and then engaging in sexual risk behaviors earlier. Conclusions such as this are outsi examined in future longitudinal studies. Findings in Relation to Theoretical Framework The findings of the study may best be explained through the lens of the social cognitive theory. The theory suggests that men viewing pornography would see the risky sexual health behaviors portrayed as rewarding or not associated with negative consequences and therefore would be more likely to imitate these behaviors (Bandura, 1977; Bandura, 1997; McQuail, 2005). The test for H ypothesis 1 did produce partial support for this relationship, in that viewing SEIM was associated with decreased condom use and increased risky sexual behaviors for some racial groups; however, it was beyond the scope of this study to determine if the men had developed a pattern of risky sexual behavior before they became regular users of SEIM. Perhaps a more likely explanation for the relationship between pornography viewing and attitudes and sexual risk behaviors is sensation seeking. Sexual sensation s eeking is a subset of sensation seeking focused on sexual risk taking and sexual adventurism. Those who are sexual sensation seekers are more likely to engage in sexual risk behaviors and may have a more positive attitude toward pornography because they vi ew it as a novel or adventurous form of media (Kalichman, 2010). Rather than SEIM use influencing behavior, it could be that these individuals who are
92 high sensation seekers are just generally more likely to seek out pornography and to engage in risky sexu al health practices. High sexual risk takers could be seeking out SEIM because they identify with others who are engaging in risky situations and derive personal validation from this. Limitations Although the current study did produce interesting, signi ficant findings, it should be noted that the research was not without limitations, including the subject pool and the nature of the study. Subject Pool and Sample Size The first limitation of the study was its small sample size. Only 85 male respondents co mpleted the survey and were included in statistical analyses. This limited the statistical power of the analyses and may have made establishing relationships among variables more difficult. Although the sample population was small, it was fairly evenly dis tributed for age and race among undergraduate college students. In terms of undergraduates enrolled in colleges similar to the University of Florida. Nationally 27.8% of stud ents enrolled in four year public universities were between the ages of 18 and 19, compared to 34.1% in the sample, 29.1% were between the ages of 20 and 21, compared to 52.9% in the sample, and 39.7% were aged 22 or older, compared to 12.9% in the sample. For race, nationally, 63.2% of students enrolled in four year public universities were white, compared to 58.8% in the sample; 12.3% were black, compared to 8.2% in the sample, 14% were Hispanic, compared to 20% in the sample, 6.7% were Asian, compared t o 2.4% in the sample, 0.8% were American Indian/Alaska Native, compared to 1.2%, and 2.8% were bi or multi racial, compared to 9.5% in the
93 proportions compared to nationa l statistics (National Center for Education Statistics, 2014). A final important note about the subject pool is that a large portion of respondents were recruited from anthropology courses involving human sexuality and culture and media courses focused on the role of television in American society. Students who are enrolled in courses involving human sexuality or the effects of media may be more in tune to the effects sexually explicit media may have on their sexual health attitudes and behaviors and thus may respond differently to a survey such as this than if they were from courses unrelated to the research questions. Nature of the Study Apart from the limitations of the sample, the cross sectional nature of the study is a limitation. The results can be interpreted only as relationships among attitudes and behaviors; it is not possible to establish causation. We cannot conclude based on this engage in risky sexual health behaviors; we can only determine that there is an association between the two. Thus, future researchers should examine these relationships longitudinally, using a nationally representative population; if the relationships identified here hold up in a more representative sample and over time, the implications for lasting effects on the health of men and women are significant. Future Research and Implications findings suggest the p otential for adverse mental and physical health effects for both
94 material influence their engagement in risky sexual health behaviors, this is an important element miss ing from current sex education programs. In a review of U.S. sometimes STI prevention (Nation al Conference of State Legislators, 2014). However, component on SEIM and pornography so that both men and women learn to understand how the unrealistic portrayals of se x they see in SEIM and other pornographic materials can mislead them and encourage poor sexual health decisions. While sex education now primarily targets sexual health through preventative behaviors such as abstinence and contraception use, this study dem onstrates that there is an association between attitudes toward pornography and risky sexual health behaviors that sex education should target. The study results also suggest that this education needs to be started early; in this sample, 17.6% of responden ts had started viewing pornography by age 10, with 89.3% reporting viewing by ages 13 to 15. With the rise of handheld Internet devices such as smart phones and tablets targeting youth at younger and younger ages, first access to SEIM may occur even earlie r as time progresses. Given that starting this type of education within schools at such a young age would be extremely difficult, if not impossible, research would need to demonstrate strong relationships of causation between pornography and risky sexual h ealth behaviors to have a chance of getting pornography conscious programming into school based sex education programs. By
95 to promoting positive sexual health behavi ors when the child grows up. Future research investigating the relationship between SEIM and sexual health behaviors and attitudes should take into account and measure for sensation seeking and sexual sensation seeking. This theory could have contributed interesting results to used in this study. The associations between attitudes toward pornography and SEIM to sexual health behaviors should be examined not only in coll ege male populations. Previous research has shown that college students were less likely than young adults not enrolled in college to engage in sexual risk behavior or high risk sex (Bailey, Fleming, Henson, Catalano and Haggerty, 2008; Bailey, Haggerty, W hite, Catalano, 2011). Thus, future research should investigate whether college enrollment influences the relationships between attitudes toward and use of SEIM and sexual risk behaviors. Although this study concentrated on males, future research should examine and behaviors. If, as previous social cognitive theory based research has shown, the beliefs of college age women can be shaped by the media they consume, it would be important to educate women about the potential effects of viewing sexually explicit internet material (Farrar, 2006). Last, race should be examined in future studies of pornography use and attitudes and sexual health behaviors because most of the rel ationships identified in this study occurred only among specific rac ial groups. Respondents in the o ther race category
96 responded significantly differently than white, black or Hispanic respondents. This warrants additional investigation into what relations hips may exist between different demographic characteristics, pornography use and attitudes and sexual health behaviors. Conclusion This research demonstrates that exposure to sexually explicit Internet material and a positive attitude toward pornography have potential implications for the sexual health of young adult males. This contributes to a better understanding of the role media can have on the sexual health behaviors of young adult males, which could have implications for the subjects sexual educat ion programs need to cover. By knowing how attitudes toward pornography are related to sexual health behaviors, educators whether they are parents or physicians could begin to bring up SEIM use as a regular part of normal sexual health conversations. If a young male were to admit to frequent use of SEIM, this could signal that he may need additional counseling on safe sex practices to try to discourage him from engaging in risky health behaviors.
97 APPENDIX A STUDENT SURVEY Please select your gender: Mal e Female Transgender Please select your age: 18 19 20 21 22 or older Please specify your ethnicity (or race): White, non Hispanic Black, non Hispanic Hispanic or Latino/a Asian or Pacific Islander American Indian, Alaska Native or Native Haw aiian Biracial or multiracial Other Please select the choice that best describes you: Straight Gay or lesbian Bisexual Other What is your current relationship status? Single In a relationship, not married Married How many oral sex partners have you had in the past year? None One Between two and five Between six and ten Between eleven and twenty More than twenty How many vaginal sex partners have you had in the past year? None One Between two and five
98 Between six and ten Betwe en eleven and twenty More than twenty How many anal sex partners have you had in the past year? None One Between two and five Between six and ten Between eleven and twenty More than twenty At what age did you first engage in oral sex? Never Age 12 or younger Between 13 and 14 Between 15 and 17 Between 18 and 20 Age 21 or older At what age did you first engage in vaginal sex? Never Age 12 or younger Between 13 and 14 Between 15 and 17 Between 18 and 20 Age 21 or older At what age di d you first engage in anal sex? Never Age 12 or younger Between 13 and 14 Between 15 and 17 Between 18 and 20 Age 21 or older At what age were you first exposed to pornography? Never Age 10 or younger Between 11 and 12 Between 13 and 15 Between 16 a nd 18 Age 18 or older
99 In the past 6 months, approximately how often have you intentionally looked at Internet (online) pictures of adults with clearly exposed genitals? Never Once One time per month One time per week Between two to six times per week Once per day More than once per day In the past 6 months, approximately how often have you intentionally looked at Internet (online) video (clips) of adults with clearly exposed genitals? Never Once One time per month Once per week Between two to six times per week Once per day More than once per day In the past 6 months, approximately how often have you intentionally looked at Internet (online) pictures showing adults having sex? Never Once One time per month Once per week Between two to six ti mes per week Once per day More than once per day In the past 6 months, approximately how often have you intentionally looked at Internet (online) video (clips) showing adults having sex? Never Once One time per month Once per week Between two to six times per week Once per day More than once per day Sexual Health Behavior Assessment I insist on condom use when I have sexual intercourse. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always)
100 I stop foreplay long enough to put on a condom (or for my part ner to put on a condom). 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) If I know an encounter may lead to sexual intercourse, I carry a condom with me. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) I engage in oral sex without using protective barriers such as a condom or rubber dam. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) If swept away in the passion of the moment, I have sexual intercourse without using a condom. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) I engage in ana l intercourse without using a condom. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) I use cocaine or other drugs prior to or during sexual intercourse. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) I engage in sexual intercourse on a first dat e. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) I avoid sexual intercourse when I have sores or irritation in my g enital area. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always)
101 I engage in anal intercourse. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) I drink alcohol prior to or during sexual intercourse. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) I ask potential sexual partners about their sexual histories. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) I insist on examining my sexual partner for sores, cuts or abrasions in the genital area. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) I ask my potential sexual partners about a history of IV drug use. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) I initiate the topic of safer sex with my potential sexual partner. 1 (Never) 2 (Sometimes) 3 (Often) 4 (Always) Attitude To ward Pornography Pornography teaches new sexual techniques. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Pornography degrades women. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree)
102 Pornogr aphy gives men false expectations about the opposite sex. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Pornography leads to sexual addiction. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Por nography is educational. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Pornography releases sexual tension. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Viewing pornography is a harmless acti vity. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Pornography degrades men. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Pornography is stimulating and exciting. 1(strongly disagree) 2(di sagree) 3(neutral) 4(agree) 5(strongly agree) Pornography gives women false expectations about the opposite sex. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Attitude Toward Condoms Using a condom requires taking tim e out of foreplay, which interrupts the pleasure of sex. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree)
103 Condoms are pleasant to use. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) The condom is a highly satisfactory form of contraception. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Having to stop to put on a condom takes all the romance out of sex. 1(strongly disagree) 2(disagree) 3( neutral) 4(agree) 5(strongly agree) Putting a condom on an erect penis (hard on) can be a real sexual turn on. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) The neatness of condoms (eg. No wet spot on the bed) makes them more attractive to use. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) The co ndom is a highly satisfactory form of STD prevention. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) The use of a condom is an interruption to foreplay. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) I see the use of a condom as adding to the excitement of foreplay if the partner helps the other put it in place. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree)
104 appeal to me. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Condoms seem safer to me than any other form of contraception. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Condoms are inconvenient. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) I think proper use of a condom can enhance sexual pleasure. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) I thin k condoms look ridiculous. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Condoms are uncomfortable for both parties. 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree) Most people do 1(strongly disagree) 2(disagree) 3(neutral) 4(agree) 5(strongly agree)
105 APPENDIX B STUDENT RECRUITMENT LETTER Dear Students -Your professors have agreed to offer extra credit for your participati on in either contact us to sign up for one of the studies. Participation in either one is worth the same amount of extra credit, which is determined by your teacher. (Your professor also has in a study.) The first study, which is intended primarily for females but is also open to males, dy image evaluations before and after exposure to a series of photographs of swimsuit models. Students who sign up for this study will first complete a brief online survey and then will be scheduled for a 30 minute lab that will be used to link answers from the online survey and the lab session. Your answers will not be linked to your name or any other identifying information. The second study, which is intended primarily for males but is open to females, asks participa nts to complete an online survey about experiences they may have had in viewing sexually explicit materials on the Internet and their opinions about such materials. Participants also will be asked for their opinions about sexual health issues. The survey d oes NOT require you to view any sexually explicit materials, and it is equally important that we have participants who have not had experience with sexually explicit online materials as well as those who have viewed such materials. Your answers will not be linked to your name or any other identifying information. Both studies have been approved by the University Institutional Review Board. Regardless of which study you complete, we will notify your professor that you should receive extra credit for your pa rticipation. We will not tell your professor which study you participated in. If you would like to participate in the first study (body image), please email Sarah Lashley ( email@example.com). To participate in the second study (sexually explicit o nline materials), please email Ashley McLain (firstname.lastname@example.org). Thanks for your willingness to help us with this research. Research Supervisor: Dr. Kim Walsh Childers, College of Journalism and Communications, email@example.com, 392 3924
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113 BIOGRAPHICAL SKETCH Ashley L. McLain was born and raised in Fort Walton Beach, Florida. After graduating from the International Baccalaureate program at Choctawhatchee High School, she attended Tulane University, and received her Bachelor of Science in Public Health degree wi th a concentration in global and community health sciences. University of Florida in mass communication with a concentration in science and health communication. With the comple tion of her graduate studies in the summer of 2014, she will receive her Master of Arts in Mass Communication degree in August 2014.