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An example of a barrier to protective behavior was seen early in the HIV epidemic, when men who were targeted for HIV risk-reduction behavior were asked to engage in behaviors, such as condom use, for which they had never been socialized. Using condoms was a new behavior for most men who had sex with men during the 1980s. The committee hypothesizes that a related barrier to adoption of condom use and reduction of unsafe sexual practices (e.g., anonymous partners) was the association of sexual behavior with self-identity. As the gay movement matured during the 1970s in the United States, a growing number of gay men equated their sexual practices with their own identity. Thus, admonitions to alter sexual behaviors were in direct conflict with the self-identities of gay men, and this conflict frustrated well-meaning attempts to alter behavior. However, this barrier is now diminishing with new generations of young Americans who have become socialized in the AIDS era.
Finally, most sexual risk-reduction efforts for STDs require mutual consent of at least two people. This requires communication about expectations, agreement on the value of engaging in protective strategies, and an understanding of sexual pleasure for each person. Communication regarding sexual behavior is problematic in the best of situations. Experience in the conduct of HIV prevention trials suggests that sexual negotiation and empowerment strategies may be perceived as meaning either that one's partner does not trust one or that there is a "hidden" reason why condom use is being added to an ongoing relationship. Neither of these perceptions builds trust or mutual respect, and these strategies may be extremely difficult to introduce into a stable relationship.
An individual needs motivation, personal skills, and interpersonal resources to implement complicated behavior changes in the face of the types of barriers discussed above. These include interpersonal communication and negotiation skills and a sense of self-efficacy regarding accomplishment of the relevant behaviors (Bandura, 1990; Wulfert and Wan, 1993). For example, individuals who are able to communicate more readily about sex appear to be more effective in their use of condoms (Brien et al., 1994; Rickman et al., 1994; Shoop and Davidson, 1994).
The best evidence that having specific skills enhances STD-reducing behavior comes from evaluations of programs that provide training in specific behavioral skills. St. Lawrence and colleagues (1995) conducted a randomized trial of an educational program versus education with behavioral skills training. The latter intervention included problem-solving skills, assertion and refusal skills, and training in proper use of condoms. African American adolescents who were sexually active and who received the latter intervention increased condom use and had a lower frequency of unprotected intercourse compared to those who received only the educational program. In addition, adolescents who had not