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2
Sexual Behavior and AIDS
It is now widely recognized that controlling the spread of the AIDS
epidemic will require a national effort to persuade a sizable fraction
of the population to modify their sexual behavior. The effort will
be most crucial for those individuals who are now sexually active
with multiple partners (concurrently or serially) and for young per-
sons who will become sexually active in future years. This urgent
need, in turn, has generated a renewed awareness of the lack of an
adequate scientific understanding of human sexual behavior (includ-
ing its emergence and development) and the necessity for rigorous
programs of basic research in this field. In this chapter, we describe
what is currently known about (past and present) human sexual be-
havior and the types of data collection efforts needed to provide basic
information from which to fashion the kind of understanding that is
now required.
STATUS OF THE RESEARCH FIELD
In the United States, research on human sexual behavior has always
been a high-risk undertaking in which there has been little public
investment. Earlier in this century, the paucity of scientific research
on human sexual behavior led to an effort at the National Research
Council (NRC) to organize and promote such research. In 1922,
with the support of the Rockefeller Foundation, the NRC established
the Committee for Research in Problems of Sex, which played a
major role in identifying and supporting fundamental research on
sexual behavior. Until it was disbanded in 1963, the committee
provided research grants and in some cases made arrangements for
73
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74 ~ UNDERSTANDING SPREAD OF HIV
direct funding by the Rockefeller Foundation for efforts ranging from
studies of hormones and the biology of sex to the pioneering social
research of Albert Kinsey and his collaborators (AberIe and Corner,
1953).
Despite the committee's efforts, however, the AIDS epidemic
has highlighted the gaps in scientific knowledge about the sexual
behavior of contemporary Americans. These gaps compromise prac-
tical attempts to cope with the AIDS epidemic and handicap efforts
by health scientists to predict its future course. For example, as
noted in Chapter 1, estimates of the number of persons infected with
HIV (Public Health Service, 1986; CDC, 1987) have used Kinsey
and colleagues' (1948) data to estimate the number of men in the
United States who have sex with men. As Chapter 1 also noted,
however, Kinsey's data have been widely regarded as unreliable for
use in making such estimates because they were not collected by
probability sampling and because they pertain to the population of
1938-1948.
Similarly, promising mathematical models of the dynamics of
the spread of HIV infection require ciata on a wide range of sexual
behaviors; these data currently are not available. For example, the
distribution of the number of sexual contacts (both current and new
partners) among indivicluals in a population has been shown to be
important to the spread of the virus (May and Anderson, 1987~. The
number of contacts is a key determinant of the "reproductive rate"
(Ro) of the epidemic, which is defined as the average number of new
cases of infection generated by a single infected individual. There
are currently no reliable ciata on sexual contacts for the national
population; there are also no such data for groups with elevated
risks of transmitting or contracting HIV infection (e.g., men who
have sex with men, TV drug users, heterosexuals with many sex-
ual partners). Indeed, there is no reliable information on the size
of the nonmonogamous heterosexual population. The lack of such
data makes predictions about the future spread of AIDS extremely
uncertain.
These examples illustrate but two of a large number of crucial
needs for reliable ciata on human sexual behavior. AIDS and HIV-
related concerns present the most pressing needs for better data; yet
over the longer term, we anticipate that the outcomes of such research
will find application in many areas besides AIDS for instance, in
population studies and in the treatment of sexual dysfunction.
In this chapter, we review the types of data on human sexual
behavior that will be needler! to understand and predict the course of
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SEXUAL BEHAVIORS ~ 75
the epidemic and to design effective interventions to bring about the
behavioral changes requirec! to control the epidemic. We also describe
the available data on sexual behavior in the United States, including
trends in adolescent and adult sexual behavior, same-gencler sex,
and prostitution; the methodological and other problems that need
to be overcome to obtain more reliable and valid cIata about relevant
aspects of sexual behavior in the United States; and the role of
anthropological techniques in this effort. Finally, we present a series
of recommendations intended to improve understanding of the sexual
behaviors that spread HIV infection.
NEEDED DATA
Two classes of data are urgently needed in the confrontation with
AIDS/HIV. One class of data is required to understand the dynamics
of HTV transmission that sustain the epidemic so as to predict the
epidemic's future course. This class includes a mix of biological
and social data. Although there may be differences of opinion on
cletail, there is widespread agreement on the common core of basic
information needled for these purposes.
Another class of ciata is needed to control the epidemic's spread
by reducing the frequency of behaviors that are likely to transmit
the virus. This class is not as well defined as the first class of data
because the task calls for a fundamental understanding of the factors
that explain the clevelopment and expression of human sexuality
(including its variety, social malleability, and other aspects).
Data Needec! to Understand the Epidemic's Future Course
Understanding the future course of the HIV/AIDS epidemic requires
both at present and at regular intervals in future years a vari-
ety of data on sexual behavior. Purely statistical extrapolations of
current trends, such as those used by CDC (Public Health Service,
1986), can provide useful short-term predictions of the number of
AIDS cases in the future, and they do not require a model of the
underlying dynamics of disease transmission. For Tong-term predic-
tions, however, it is necessary to understancl the underlying dynamics
of transmission within particular risk groups (see, e.g., May and An-
clerson, 1987~. Such understanding in turn requires more extensive
knowlecige of three key elements of HIV transmission.
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76 ~ UNDERSTANDING SPREAD OF HIV
First, it is necessary to know the probability that an infected
inctiviclual will transmit the infection to a partner (including male-
to-male, maTe-to-femaTe, female-to-maTe, or female-to-femaTe trans-
mission through sexual acts or by needle-sharing). The transmission
probabilities in these instances depend on the kind of contact in
question and the duration of the partnership, as well as on a variety
of other factors. Transmission probabilities are not well understood
at present; they are probably most uncertain for heterosexual trans-
· . .
mlsslon.
Second, data are needed on the rates of acquiring new sexual
partners (or neecIle-sharing partners) among specific groups. Such
ciata include not only the average number of new sexual partners
acquirer! each year but the variation in this number as well. Persons
who acquire new partners at a high rate play a (disproportionate
role in the transmission of infection, as they are both more likely
to acquire and more likely to transmit infection. Thus, in both an
epiclemiological and a mathematical sense, sexual contacts (or neecIle-
sharing contacts) in a group cannot accurately be characterized by
"average" individuals or "average" behavior. Data are also needed
on the relative frequency of behaviors that have markedly different
likelihoods of transmitting infection (e.g., anal, vaginal, or oral sex).
Similarly, information is needed about the extent to which awareness
of HIV/AIDS transmission has altered behavior (particularly with
respect to the use of condoms and spermicides) in ways that may
reduce transmission.
Third, it is essential to know some key facts about the natural
history of HIV infection, an area of knowledge in which, currently,
uncertainties abound. There is considerable variation in the time
that elapses between a person's acquiring HIV infection and the
appearance of full-blown AIDS. The current best estimate is that the
mean incubation period is ~ years, but as data spanning more time
become available, it seems likely that this estimate will increase.)
There is also uncertainty about the time-course of infectiousness.
Evidence is now accumulating that suggests that infectiousness varies
over the course of the disease. It appears that it may be elevated in
the early phase of HIV infection and again at the onset of AIDS itself
(as the immune system colIapses) but that it may remain relatively
1The current estimate is that the majority of HIV-seropositive individuals will go on to
develop AIDS, and it is not impossible that 100 percent of seropositive individuals may
eventually develop full-blown AIDS (IOM/NAS, 1988:35-36~. See also the projections
of Lui and colleagues ( 1988~.
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SEXUAL BEHAVIORS ~ 77
Tow at other times (e.g., TOM/NAS, 1988:38; Anderson and May,
l988:Figure 1~.
The basic reproductive rate (Ro) of an infection within a partic-
ular population determines whether the infection has the potential
to generate an epidemic in that population. The reproductive rate is
essentially the number of new cases of infection produced, on aver-
age, by each infected individual in the early stages of the epidemic,
when essentially all contacts are themselves not infected. So, for
example, if Ro is less than 1.0 for heterosexual transmission of HIV
in the United States, on average, each case of HIV infection will
produce fewer than one subsequent case, and the process will not
be self-sustaining. There will be some chains of HIV transmission in
which men will infect women who will then infect men and so on, but
they will be few and short. If Ro is larger than 1.0, however, such
chains will be more numerous and longer, and a "chain reaction," or
epidemic, will be generated. The larger the value of Ro, the shorter
the time it takes for the number of cases of infection to double.
It is clear that Ro exceeded 1.0 among gay men in large U.S. cities
in the late 1970s and early 1980s and that it exceeds 1.0 today among
{V drug users who share needles. It is also clear that Ro exceeds 1.0
among the heterosexual populations of many parts of Africa. At
present, it is unknown whether Ro is large enough (greater than
1.0) to engender a self-sustaining epidemic with purely heterosexual
chains of transmission in the United States.
The basic reproductive rate for a defined risk group depends
on the three factors discussed earlier: the transmission probability,
contact rates, and duration of infectiousness in that group. In the
early stages of an epidemic, Ro can be estimates! by multiplying
the values of these three factors: the probability that infection will
be transmitted to any one new contact (sexual or needIe-sharing
partner), the average number of new contacts each year, and the
number of years over which the infected incliviclual remains infectious.
It should be noted that the reproductive rate for HTV infection
combines the fundamental biology of the virus (which determines
the incubation interval, for example) with behavioral factors (e.g.,
rates of acquiring new sexual partners, whether condoms are used,
and so forth). Thus, Ro can differ from one risk group to another
and can change over time in response to behavioral changes.
If Ro for heterosexually transmitted HTV in the United States is
less than 1.0, no "second-wave" epidemic, spread purely by hetero-
sexual contact, is possible. Moreover, even if Ro does exceed 1.0 in
the heterosexual population, the doubling time for the second-wave
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78 ~ UNDERSTANDING SPREAD OF HIV
epidemic may bear little relation to that of the "first wave," which
spread mainly among gay men and {V drug users. Furthermore, if
the cloubling time of this second, heterosexual wave is much longer
than that of the first wave for example, 5-10 years or more the
resulting patterns of spread among heterosexuals may go unnoticed
against the much larger background of cases among homosexuals and
{V drug users.
Data Needler! to Unclerstanc! the Epiclemic's Dynamics
Estimating future demands on hospitals and other public health ser-
vices requires reliable models of HIV transmission dynamics. Such
epiclemiological models, in conjunction with knowledge of the under-
Tying biological and behavioral variables, can also help in assessing
the relative effectiveness of different kinds of behavioral change and
guiding the development of effective public health education.2
Data neecis are driven by immediately relevant questions of dis-
ease transmission, progress, and control. The resulting intellectual
strategy is to design new research looking for the "facts about sex"
in order to answer those questions. Such facts, particularly when
reliably collected and combined with a sensitive understanding of
the cultural boundaries between social groups, may be of consider-
able use in the medical and social management of the HIV/ATDS
epidemic. Yet the committee would point out that there are risks in
a strategy of proceeding from an interest in disease to research on
the "facts" of sexual conduct. These risks involve the possibility that
concerns about disease will reinforce the tradition of treating some
aspects of sexual conduct as social or medical "problems."
To understand the motives, clevelopment, and varieties of human
sexual behavior, it is crucial to understand the systems of meaning
and action—the cultural context in which the "facts of sex" are
embedded. The facts remain the same, but understanding may differ.
Different understandings in turn may have important consequences
for designing effective educational efforts to encourage self-protective
behaviors.
2Efforts to reduce risky behavior in individuals often do not require detailed knowledge
of the transmission dynamics of the epidemic. Nevertheless, efforts directed toward
accessible individuals can go hand in hand with broader, population-level studies of
the relative effectiveness of different broad categories of public education. Individual
counseling and activities to reduce risky behavior in particular groups that are accessible
to AIDS prevention efforts are not alternatives to mathematical modeling, given that
such modeling may lead to the development of intervention strategies that make maximal
use of scarce resources.
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SEXUAL BEHAVIORS ~ 79
In the following sections of this chapter, we review available data
(largely collected prior to the onset of the AIDS epidemic) on sexual
behavior in the United States. The history of research on human
sexuality, at least in the United States, can be divided somewhat
crudely into the pre-Kinsey and post-Kinsey eras. Despite the fact
that Kinsey himself cited a number of questionnaire and interview
surveys of sexual behavior conducted in a variety of countries as early
as the first decade of the twentieth century (Kinsey et al., 194S, 1953),
it was the publication of the two "Kinsey reports" Sexual Behavior
in the Human Male (1948) and Sexual Behavior in the Human Female
(1953) that dramatically shifter! the study of human sexuality away
from its predominantly clinical and psychopathological concerns. In
doing so, Kinsey and his coworkers respondent to the call of Havelock
Ellis in the 1920s, who proposed that sex researchers expand their
interests beyond the asylum, the prison, and the clinic to study
"fairly normal people" (Gagnon, 1975~. In the attempt to accomplish
this task, no matter how provisionally, the Kinsey studies helped to
change the way in which sexuality was approached in American
society: first, by establishing sexuality as a legitimate object of
scientific inquiry; second, by offering a blurred but still discernible
"snapshot" of what some people were (loin" sexually; and thircl,
by offering a different definition of what was thought to be norma1t
sexuality.
THE KINSEY STUDIES
It is not easy for those who have grown up in the 1960s and later
to understand the extraordinary impact of the Kinsey studies in a
society in which ignorance about sexuality was pervasive. Even those
who were already adults when Kinsey's work first came to the na-
tion's attention probably find that their memories of that world have
been corroclec3 by time and the deluge of sexual materials andref-
erences that have characterized the past three decades. The Kinsey
studies engendered extensive, if not always thoughtful, discussions
of sexuality in a society in which public talk about sex had been
restricted to the vulgar, the moralistic, or the psychoanalytic. After
their publication, words such as masturbation, homosexuality, or-
gasm, vagina, extramarital sex, clitoris, and penis could be spoken of
in more or less polite company (although not in the New York Times
of the period). People knew (or thought they knew) that one man
in three had had sex at least once with another man; one married
woman in four had sex outside of marriage; and the average rate of
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80 ~ UNDERSTANDING SPREAD OF HIV
intercourse in marriage was between three and four times a week for
couples in their 20s. The "facts" were out of the closet and seemed
unlikely to be put back in. The vast outpouring of public discussion
was based on what were two Tong and seemingly indigestible books,
the first reporting approximately 3,000-5,0003 face-to-face interviews
with men, the second reporting 5,940 similar interviews with women.
Quality of the Kinsey Data
Because the Kinsey studied are cited even today as a primary source
of information on sexual behavior, it is valuable to review their
design. To assess the quality of these data and their appropriateness
for estimations of contemporary sexual behavior, it is important to
examine two methodological aspects of the Kinsey studies: (1) the
interview scheclule, including its topical coverage, the interviewing
procedures, and the interviewers; and (2) sampling—the method
of gathering cases. These two aspects are discussed below; a third
major aspect, the impact of the Kinsey studies on conceptions of
sexual normality, is discussed later in the chapter.
The Interviews
The greatest strengths of the Kinsey studies were probably their
coverage of a wide variety of sexual topics and the quality of the
interviewing. The theories that informed the interview were quite
general; they primarily reflected Kinsey's prior training as a tax-
onomist who had made his reputation in the ecological and evolu-
tionary stucly of the gall wasp. Kinsey was fun(lamentally interested
in the behavioral events (as opposed to the attitudes, motives, or
emotions) that composed an individuaT's sexual history, and he saw
those events as expressions of the interaction between the universals
3This range reflects the fact that different analyses reported in the first volume were
done at different times and that during the intervals, additional cases accumulated.
(A Oh h ~ or] ~ n r1 T^h ~ curare ~ 1 (] 7(] . Cl ~ ret ~+ Hi. ~~
~_V^~ .L VVAAAA~VAI. ~~-I-.-J revue. ... in those days we lacked computers and our
card sorters were slow. A relatively simple table could easily take a full day or two
of sorting assuming the machine was available. Consequently, some tabulations were
made a year or more before others and since our interviewing continued, our Ns varied.
Thus, Table 62 in the Male volume tSexual Behavior in the Human Male] shows 3,012
white males in our earliest age category (which should include all post-pubescents), yet
in Table 63, the number is 3,925. Still later in Table 92 the N has risen to 4,625. This
particular table was made in May 1947 one of the latest prepared."
4Additionally, the volumes Pregnancy, Birth and Abortion (Gebhard et al., 1958),
Sex Offenders: An Analysis of Types (Gebhard et al., 1965), and The Kinsey Data:
Marginal Tabulations of 1938-1963 Interviews Conducted by the Institute for Sex Re-
search (Gebhard and Johnson, 1979) contain important information about these studies.
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SEXUAL BEHAVIORS ~ 81
of the mammalian heritage and the specifics of social learning in a
cultural context. The interview thus embodied a general scientific
perspective rather than a specific set of hypotheses to be tested.
The interview schedule consisted of a dozen topical areas that
could be covered in approximately 300 questions (Gebhard and John-
son, 1979:13-14~. Interviewers were not restricted to the specific
framework of the schedule, however, as the goal was to obtain infor-
mation in an area rather than to ask precisely worded questions. The
interviewers memorized the schedule, changed wording to conform
with usage by the interviewee, and recorded only coded responses (to
maintain confidentiality). The schedule was designed by Kinsey in
the late 1930s and was consoliciated by the early 1940s. Its continuing
use had the benefit of maintaining comparability in data that were
collected over nearly 25 years, although at some cost to the ability
to learn from mistakes or adapt to new knowlecige.
Kinsey wanted the social interaction involved in the interview
process to be businesslike and nonjudgmental. Nothing was to be
disapproved of or found shocking by the interviewers. Interviews
were most often conducted outside the home, in institutional or com-
mercial settings in which appointments could be ma(le and anonymity
preserved.
Almost every possible sexual topic was included: people were
routinely asked about masturbation, nocturnal orgasm, intercourse
(in all its variations), homosexual contacts, animal contacts, and sex-
ual fantasies. Respondents were asked in considerable detail about
the ages at which they engaged in these behaviors, frequencies, tech-
niques, partners (when appropriate), and rates of orgasm. Those
inclivicluals with extensive histories of homosexuality, prostitution,
sex offenses, sadomasochism, and the like were queried still further.
Few studies conducted since that time have been as sharply focused
on sexual behavior or so exclusively interested in sexual conduct
for its own sake. More recent studies of sexual behavior have often
asked only a few questions about sexuality, usually in the context
of another inquiry that was defined by some social problem (e.g.,
adolescent pregnancy).
There are significant differences between the Kinsey interview
and the interviews that characterize most modern surveys. Current
surveys that use face-to-face (lata gathering usually have fixed inter-
view scheclules; interviewers are required to conform to the precise
wording and order of questions printed on the survey questionnaire.
In adclition, a changing technology of data gathering has produced
other variations:
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82 ~ UNDERSTANDING SPREAD OF HIV
· survey interviewers are most often women, many inter-
viewers are involved in each survey, and interviews are
often done in the subject's home;
· most surveys even studies that have some relation to
sexuality (e.g. studies of reproduction and fertility) do
not focus entirely on sexual matters but instead ask such
questions infrequently and usually as modest additions;
and
. in many cases, interviews are conducted by telephone.
Sampling
It has long been recognized that one of the greatest faults of the
Kinsey research was the way in which the cases were selected: the
sample is not representative of the entire U.S. population or of any
definable group in the population. This fault limits the comparability
and appropriateness of the Kinsey data as a basis for calculating the
prevalence of any form of sexual conduct.
The population segment best represented by the Kinsey inter-
views can be described as a "chunk" of the white, youthful, college-
educatecl U.S. population whose adolescence and young adulthood
were lived during the late 1920s, the Great Depression, and World
War Il. Of those interviewed, 96 percent were white, and their median
age was 24;5 moreover, 68 percent of those interviewed were 30 years
of age and younger and were thus able to offer evidence on only the
first quarter of adult sexual life. Some respondents were specifically
chosen because they were delinquents, criminals, or sex offenders;
5This and subsequent characterizations of the Kinsey cases are taken from Gebhard
and Johnson (1979:47-51, Tables 1-3~. This particular description refers to Kinsey
cases interviewed at any time from 1938 to 1963. (Table 2-1 shows the number of
cases collected during different periods.) Gebhard and Johnson's (1979) tabulations are
restricted to what they call Kinsev's "basic sample," which they define as including
"postpubertal individuals who were never convicted of any offense other than traffic
violations and who did not come from any sources which we knew to be biased in terms
of sexual behavior" (p. 41~. This basic sample included 177 black men, 223 black women,
4,694 white men, and 4,358 white women, all of whom had attended college for at least
one year. The basic sample also included 766 white men and 1,028 white women who
had not attended college.
Kinsey's basic sample does not include cases identified by Gebhard and Johnson as
(1) homosexual (defined as "postpubertal individuals who had at least 50 homosexual
contacts or who had at least 20 sexual partners of the same gender as the individual"
[p. 43~; (2) delinquents (defined as "postpubertal individuals who have been convicted
of a felony or misdemeanor other than a traffic violation" tp. 453~; and (3) "special
groups," which are described as "simply residual categories of individuals who cannot
be assigned elsewhere because of some sample bias or because of some other special
characteristic" (p. 45~. This last "residual" group included 380 prepubertal and 999
postpubertal males, and 156 prepubertal and 717 postpubertal females.
,. ..
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SEXUAL BEHAVIORS ~ 83
TABLE 2-1 Year of Interview by Gender for Persons Interviewed Using
the Original Kinsey Interview Schedule
Males
Year
Females
Number Percentage Number Percentage
Prewar,
1938-1941 1,910 19.5 436 5.6
Wartime,
1942-1945 3,353 34.3 3,740 48.4
Postwar,
1946-1952 2,907 29.7 3,413 44.2
Early 1950s
1953-1956 1,461 14.9 58 0.8
Post-Kinsey,
1957-1963 146 1.5 78 1.0
Total 9,777 7,725
SOURCE: Gebhard and Johnson (1979).
most of the remainder were, in the tradition of most sex research,
college eclucated. About 84 percent of the men and women inter-
viewed hac! some college education, and 45 percent were in college at
the time of the interview. Perhaps most striking is that 25 percent
of the college-educated women had been to graduate or professional
school, as hacT 47 percent of the college-educated men. About one
half of the female sample was interviewed during World War II, and
many others were interviewed shortly afterward (see Table 2-1~.
Perhaps more important than the composition of the sample were
the methods by which the cases were collected. Both the difficulties
of sampling on a sensitive topic ant! Kinsey's confidence that the
sheer force of accumulated cases6 would eventually translate into
representativeness severely compromised the usefulness of the data
for making estimates of prevalence that coup be generalizecI to any
larger group or to the overall population.
Kinsey gathered cases in a variety of ways. Many respondents
were interviewed as the result of gaining access to a group through
a contact person: for example, a faculty member sympathetic to
Kinsey's goals might allow him to speak to a class to recruit students,
or a prison administrator would offer access to an inmate population.
6Kinsey hoped to gather lOO,OOO interviews to complete his research (see the dedication
to the 1948 volume); some 17,000 had been completed by the time of his death.
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SEXUAL BEHAVIORS ~ 175
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Representative terms from entire chapter:
sexual behaviors
