Cover Story

A high school girl meets a boy from class at a party. He flirts with her, and she flirts back. Eventually, they begin to kiss, and he asks her to go somewhere private.

What happens next in this scene from an interactive video is the decision teenagers face in a new intervention developed to teach sexual-behavior risks.

"The video provides a cognitive rehearsal session where teenagers can apply generic points they have learned to actual situations," says psychologist Julie Downs, PhD, director of the Center for Risk Perception and Communications at Carnegie Mellon University. "This allows them to practice applying these skills and knowledge before they are thrust into a situation where there are huge sexual scripts driving them."

Such practice with sexual scenarios is needed, says Downs, because researchers have found that many young people--despite awareness of the risks--continue to engage in high-risk sexual behavior anyway.

As such, about 870,000 pregnancies occur each year among women 15-19 years old, and about 3 million cases of sexually transmitted diseases (STDs) among 10-19 year olds are reported annually, according to the Youth Risk Behavior Surveillance study by the Centers for Disease Control and Prevention (CDC).

Ignoring the risks

Why do so many turn their backs on the risks?

"Why do so many people continue to smoke when the risks are known, or why do they continue to drive without seatbelts?" counters Tom Coates, PhD, director of the Center for AIDS Prevention Studies (CAPS). "People do a lot of dangerous things. This needs to be looked at within the same light. It shouldn't be a surprise that they don't act on information they are given."

Some might be more risk-prone or unrealistically optimistic that they are at less risk, studies suggest.

Substance or alcohol abuse also might impair judgment, Coates notes. The CDC's Youth Risk Behavior Surveillance showed an 18 percent increase from 1991 to 2001 in numbers of high school students using alcohol or drugs before recent sexual encounters.

To others, the consequences of engaging in a high-risk sexual behavior may not seem as severe as they once did, Coates adds. "There used to be visible signs of people sick with HIV or AIDS, and that's no longer the case," Coates says. "People live longer and reasonably well with antiviral medications. So prevention in this era becomes more complex than in previous eras when HIV was viewed as more deadly and scary."

Also, infusing moral messages into discussions about sexual behavior can lead teenagers to distrust the information they are given, Downs adds. Some assume that the information exaggerates the risks to persuade them not to have sex rather than seeking to help them make informed decisions, she says.

The tendency to engage in high-risk sexual behavior can continue on to adulthood as well, studies have found. To find out why people ignore the dangers, researchers examined sexual risk-taking in more than 1,500 men through a two-year study--currently being reviewed for publication--by the Kinsey Institute, an Indiana University center for human sexuality research.

The study shows that personality traits--such as sensation-seeking, sexual inhibition and excitation, mood, and assertiveness--play a role in decisions to take risks. In the study, men with high sensation-seeking scores or depression were more likely to participate in risky behavior they later regretted, and several also reported that sexual arousal impeded their judgment, says Erick Janssen, PhD, psychologist and associate scientist at the Kinsey Institute. Janssen says they mainly focused on men's risky behavior in this particular study because the theoretical model they used was based on research about men.

By identifying traits of those more apt to ignore the dangers, Janssen hopes the center's research can eventually be used to develop tailored intervention and prevention programs to help sexual risk-takers better understand their behavior and increase their control.

Creating interventions

Meanwhile, psychologists are already developing and using more general behavioral intervention and prevention programs--like Carnegie Mellon's--to help young people communicate about sex and its risks. Research has shown interventions that provide training in assertiveness and sexual communication skills may help encourage safer sex.

In Carnegie Mellon's interactive video, for example, teenagers are given three options after each scenario--such as in one scenario where two teenagers contemplate having sex: "I want to, but not today," "We can't do this" or "How long will [your parents] be gone?" The options are not just "yes" or "no," Downs says, because real-life situations are not usually so clear-cut.

When the teenager chooses a low-risk behavior for the girl in the video (refraining from sex or using a condom), the video then shows the boy trying to pressure her while the girl remains steadfast in her decision. When a high-risk option is chosen, no reinforcement is provided. All teens are eventually directed to a portion in the video where the girl chooses to bring a condom with her and refuses to have sex without it.

Yet another psychologist-developed intervention to reduce risky sex is the Mpowerment Project, a community-based HIV prevention program for 18-to 29-year-old gay or bisexual men. Founded by psychologist Susan Kegeles, PhD, and the late Robert Hays, PhD, the program focuses on community-building, personal and community empowerment, and peer-led activities. The program was piloted in Eugene, Ore., from 1991 to 1992. Participants were surveyed twice, once after finishing the nine-month intervention and again a year later.

Researchers found the number of participants who engaged in unprotected anal intercourse dropped from 41 percent to 30 percent; 20 percent to 11 percent with nonprimary partners; and 59 percent to 45 percent with boyfriends. The results were documented in the American Journal of Public Health (Vol. 86, No. 8).

"We really put our psychological research into action in fighting this epidemic," says Kegeles, the project's principal investigator and associate director of CAPS.

The intervention has been tested in three more communities since then and is now being implemented in community-based organizations across the United States. So far, 60 HIV-prevention specialists have undergone a three-day training program to apply the model in other cities.

Other intervention programs are also drawing on psychological research to help get the message out. For example, the three-session PARTNERS Project--supported by the CDC and targeted to women 18-25 years old and their partners--emphasizes that there may be risks no matter how long the relationship. The program aims to help couples develop personalized plans for safer sex and improve couples' communication about it. Outcomes involving 303 couples at the two test sites--Los Angeles and Oklahoma City--are currently being analyzed.

Through these interventions, psychologists say they hope couples will more effectively communicate about sexual risks. That often means squashing common misunderstandings people can have from information they are given in sex-education classes and public-service announcements, says Carnegie Mellon's Julie Downs.

To help, Downs has created informational pamphlets. In them, she offers further explanation of such statements as "You can get an STD the first time" and provides suggestions for how to "Know your partner," including asking a partner about STD testing.

"We often give teenagers information that makes a lot of sense to us as public health officials, or as we understand the problem," Downs says, "but that often doesn't fit into the perspective of a teen decision-maker."