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Article Excerpt
The desire for a woman-initiated disease prevention method has increased the attention on vaginal microbicides as a method for the prevention of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). Microbicides are substances that may reduce transmission of STIs (Wulf, Frost, & Darroch, 1999) and may also prevent pregnancy, although not all microbicides will be contraceptive (Harrison, Rosenberg, & Bowcut, 2003). Currently there are more than 30 microbicide formulas in differing phases of clinical trials, including two products in the final phase of clinical trials (Alliance for Microbicide Development, 2007). Development delays have primarily been attributed to the complex physiology of the vaginal environment and research funding mechanisms (Global Campaign for Microbicides, 2007). Similar to spermicides, which have shown a range of acceptability (Elias & Coggins, 2001), including women's discontent with timing of insertion (Raymonda et al., 2005), microbicides would be inserted into the vagina at each coital event. In addition to prevention properties, microbicides may impact sexual comfort and pleasure, as most formulas will have lubricating qualities (Braunstein & Van de Wijgert, 2005; Philpott, Knerr, & Maher, 2006; Zubowicz et al., 2006). Therefore, microbicides offer a unique compromise between the reduction of infection risk and potential influence on sexual performance and pleasure.
Historically, microbicide development has been situated in the need for a woman-controlled method of protection against STIs, as it is suggested that underlying gender inequalities limit women's abilities to protect themselves and ensure condom use (Elias & Heise, 1994; Potts, 1994; Stein, 1990). Thus, the anticipated arrival of microbicides, a woman-controlled method, is considered by many to be a significant advancement in public health's efforts to control STI and HIV incidence. An inherent contradiction exists, however, in the promotion of a "woman-controlled" method to be used by a woman for the protection of her own body. The rationale for microbicide development has been based on the assumption that women have less control than men in sexual decision making (Pulerwitz, Amaro, De Jong, Gortmaker, & Rudd, 2002). In suggesting that women actually do not have control of their bodies or their sexual behaviors, this argument implies that women may not, in fact, be able to effectively adopt a woman-initiated method. Much research has documented a gendered power imbalance in heterosexual relationships, for example, in terms of sexual and contraceptive negotiation and violence (Blanc, 2001), which will be problematic for women as they negotiate and use microbicides within this relational context. Recent work in the United States has indicated, however, that some women describe more equal relational power dynamics and feel in control of their sexual bodies (Carpenter, 2002; Harvey, Bird, Galavotti, Duncan, & Greenberg, 2002). Thus, microbicides--if they become available--may be helpful in facilitating dialogue around these gender power issues, at least in the United States.
To more fully understand how microbicides may (or may not) be used, it is essential to understand how people, more specifically women, negotiate heterosexual norms. The social rules governing relationships often transform women's bodies into a shared space. The physical requirements of heterosexual intercourse (vagina accepting the penis) suggest that a woman's body, specifically her genitals, becomes a cooperative space where others, primarily male partners, have significant influence on how the space is defined. This is particularly relevant in the context of previous research suggesting women's sexual motivation is often based on a desire to please their male partners (Nicolson & Burr, 2003). The construction of women's bodies as a shared space suggests that women's preferences for microbicides need to be situated within the social context in which they will be used.
Research on young women's sexuality has generally adopted a deficit approach. It has problematized their (hetero)sexual behavior and reduced their sexuality to the potentially negative outcomes, such as unintended pregnancy and STI (for a critique see Fortenberry, 2003). Additionally, existing research has largely focused on the individual woman and ignored the broader cultural context in which her sexual behaviors occur. The intersection of multiple identities for young women--gender, ethnicity, age, and socioeconomic status--all play a role in how young women negotiate their sexuality, sexual behaviors, and contraceptive use (Dworkin, 2005; Orbuch & Fine, 2003; O'Sullivan & Meyer-Bahlburg, 2003). A consequence of the problem-based approach to research on young women's sexual behavior is that little work has been conducted on their sexual pleasure (Welsh, Rostosky, & Kawaguchi, 2000) or sexual desire, suggesting a "missing discourse of desire" for young women (Fine, 1988; Fine & McClelland, 2006).
Microbicides will be unique in having disease prevention properties and characteristics that may positively impact sexual performance, pleasure, and comfort. These qualities offer a catalyst to shift research on young women's sexuality from a problem-based to a broader gender and sexuality perspective. This broader approach is needed in microbicide research to provide a positive construction of young women's sexuality while at the same time examining the benefits of protection. Several researchers have suggested that it is time to address the overall healthy sexual development of young people (Tolman, 2006; Welsh et al., 2000). Welsh and colleagues (2000) proposed a framework including personal characteristics and ecological variables (i.e., culture, family and peer environments) as factors influencing young women's sexual behavior. The consideration of these factors is essential, especially for future microbicide use and acceptability, as social and cultural norms have considerable effects on sexual behaviors.
In order to address the complex integration of a microbicide into the sexual repertoire of young women, it is important to understand the meanings associated with their bodies, sexual behaviors, sexual partners, and the product. Symbolic interactionism and sexual scripting theory are useful in framing how women associate meanings across a variety of contexts (Gagnon, 1990; Gagnon & Simon, 1973; Longmore, 1998; Plummer, 2003). Symbolic interactionism focuses on shared understanding and is useful in considering the value that young women may place on microbicides (Longmore, 1998; Plummer, 2003). Sexual scripts exist at three different levels: intrapsychic, interpersonal, and cultural scenarios and allow individuals to determine the appropriate sequence of sexual interactions (Gagnon, 1990; Gagnon & Simon, 1973). These frameworks allow women to construct the role that sex plays in their lives and how these constructions are fluid depending on the physical and social environments. An understanding of how the sociocultural contexts influence sexual behavior scripts is useful in considering how microbicides may (or may not) be utilized in sexual interactions.
The purpose of this study was to examine qualitatively the influence of specific factors on young women's use of a microbicide surrogate, a vaginal moisturizer (VM). As microbicides are not yet approved, some previous research has utilized VMs as surrogates for microbicides (i.e., Zubowicz et al., 2006) in order to assess the behavioral correlates of use above and beyond hypothetical product assessment. The specific aims of this study were to examine how factors related to individual and social characteristics as well as features of the product might affect use and sexual pleasure. A better understanding of the factors influencing use of a microbicide surrogate will be useful in the promotion of future microbicides.
Method
Study Design
This study was part of an ongoing longitudinal study of young women's sexual health and...
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