Perceptions of Sex and Sexual Health

Among College Men:

Implications of Maladaptive Habits in Physical and Social
Relationship Formation
Michael J. Rovito,
FRank Johnson
kathy e. vazquez
aMy elliott
sandi coRnell
Melanie tivis

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Fear, vulnerability, stigma, and masculinity are important concepts to consider when promoting health
among males. However, most health education efforts targeted towards males, particularly college-
aged males, do not fully grasp the influence of these variables upon men to assist with them adopting
healthier romantic and sexual relationships.
This discussion presents trends from a university-based seminar during the 2011-2012 academic
year conducted with college students on maladaptive sexual habits, including promiscuity, subjective
norms of sex and relationships, alcohol abuse, and inconsistent STD protection, as they pertain to
physical and social relationships. Approximately 225 college-aged men and women attended the sem-
inar. A particular emphasis was placed on perceived masculinity and gender roles within the social
environment and how they influence physical and social relationship formation.
The seminar was a first step for future effectiveness testing of message-delivery systems in re-
lationship and sexual health behavioral modification research among college men. This paper presents
lessons learned from this exploratory approach in community health outreach efforts. We advocate
that such seminars can be an efficient and effective way to raise awareness and promote wellness
among male college students.

keywords: sexual health, college men, relationships, gender, risk perception

Men’s health disparity and Barriers to services

Studies show that men are living sicker and dying younger than females at every stage of
life (Leone, 2012; NCHS, 2009; Jeanfreau, 2011; Centers for Disease Control and Prevention, 2010;
Singh-Manoux et al., 2008). This trend is perhaps most evident in college-aged individuals (ages
18-25), where 3 out of 4 deaths are men (APHA, 2011; CDCP, 2007).

It is commonly accepted that men generally seek health care less often and later in a dis-
ease process than women (Jeanfreau, 2011; APHA, 2011; Gottlieb & Green, 1984). Men face several
barriers to health service utilization. For example, low-income and less-educated men face sys-
temic challenges that serve to disengage them from health care access. These include a lack of af-
fordable health care coverage as well as infrequent, perhaps even inadequate, medical counsel
from primary care providers (The Commonwealth Fund, 2000). Further, a man’s need to stay in
control, take risks, and deny the severity of physical ailments leads him to avoid seeking health-
care until it is completely necessary (Jeanfreau, 2011).

Men are also less likely than women to have a holistic perspective of health, viewing their
bodies mechanistically, underreporting to their medical providers the total range of symptoms
they may be experiencing (Furman, 2010). In an effort to prove their masculinity, men often be-
have in ways that greatly increase their risk of disease, injury, and death (Courtenay, 2011). Torres
et al. (2002) suggests that masculinity may be protective in some regards to healthy lifestyles, but
for the most part acknowledges the negative affect it has upon certain cultures of men and how

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they perceive societal gender roles. For example, machismo may assist in repressing emotions, fail-
ing to report symptoms of disease, suppressing the desire to seek help from others, increasing the
hypersensitivity of men in feeling ‘unmanly’, and thus possibly lending to the trend of rising mor-
bidity and mortality rates. (Nicholas, 2000; MacNaughton, 2008)

College-aged men may be particularly at risk for underutilization of health services. Jeanf-
reau (2011) suggests that this may be due to the fact that men are not likely to seek health care after
their mothers and/or fathers stop scheduling appointments for them. Health services are generally
free at the university level, but young men often display a lack of perceived vulnerability which
keeps them from seeking these services (Davies et al., 2000). When asking men in college about
their barriers to seeking health services, Davies et al. (2000) found that most males have a great
need to be independent and conceal any weakness or possible susceptibility. Several young men
revealed that because of their fear of being judged by their peers, they would not seek help for
medical or emotional problems unless they were in extreme emotional or physical pain (Davies et
al., 2000; Jeanfreau, 2011). Other reported barriers to health services include lack of time (effi-
cacy), lack of knowledge/awareness, and lack of trust in healthcare providers (Jeanfreau, 2011).

Davies et al. (2000) also asked college men in focus groups to make suggestions about what
would make it easier and make them feel more inclined to seek help. Several men said that
graphic pictures and stories from peers who had experienced major health issues would increase
their awareness of health risks, lending credence to components of the Fear-Drive Model. Gibbons
and Gerrard (1995) illustrate how men were more likely to demonstrate a correlation between how
they perceived negative images and change in risky behavior. They further demonstrated that the
images of negative results related to risky sexual behavior have an effect in reducing these behav-
iors.

sexual health of college students

Several studies show that college students do not consistently practice safe sex (Smith et
al., 2009; ACHA, 2006; Holland et al., 2012). The American College Health Association (2006) re-
ported that 82% of students did not consistently use condoms during intercourse and 33% of
those students never used condoms. Experts estimate that about 50% of reported cases of sexually
transmitted diseases (STDs) are from college-aged individuals (Weinstock et al., 2000). These
rates might be higher due to the fact that college students frequently have sex while under the in-
fluence of drugs and alcohol, have casual sex with multiple partners, and inconsistently use con-
doms and other types of birth control (Turchik & Gidycz, 2012; de Visser, 2007; Laska et al., 2009;
Ravert et al., 2009).

While rates of STDs are steadily climbing among college students (CDC, 2007), 66% of
young adults between the ages of 18 to 24 have never been tested for STDs (Johnson et al., 2010).
This may be because college students misjudge their risk of contracting STDs, underutilize serv-
ices, and/or associate a negative stigma with being tested. Sandfort and Pleasant (2009) asked over
1,500 students to rate their risk of contracting an STD. The mean score based on a 5-point scale
was 1.65, indicating that students are underestimating their risk of contracting an STD (Sandfort
& Pleasant, 2009).
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Men may be particularly at risk for contracting STDs because they engage in intercourse at
an earlier age, have more partners, are more likely to have sex while under the influence of drugs
or alcohol, are more likely to engage in anal sex, and are more permissive to casual sex and sex out-
side of marriage (Petersen & Hyde, 2011; Ahrold & Meston, 2010; Davies et al., 2000). These traits
may place college-aged men at an increased risk compared to their female counterparts.

Lack of knowledge may play a role in a students’ choice to engage in risky behaviors. Car-
rera et al. (2000) gave a sexual knowledge quiz to a sample of college students and found that the
average student only got 44% of the questions correct. Further, Jeanfreau (2011) and Sandfort and
Pleasant (2009) suggest that men may have considerably less knowledge than their female peers
about health in general, and specifically about sexual health, which can have a significant influ-
ence upon their decision-making skills regarding sexual behaviors.

sexual health education for college students

Sexual health discussion can be fascinating to young adults, but it can also be a very sensi-
tive subject to discuss with family, peers, partners, or healthcare providers (Buhi et al., 2009;
Hutchinson & Montgomery, 2007). Duly, there is a difference between where students prefer to get
information on sexual health and where students actually get information on sexual health. When
asked about their primary sources of information regarding sexual health, only 4% of college stu-
dents listed their physician. Students more commonly listed television commercials, friends and
relatives, and the internet as their primary source, not a physician nor any other health profes-
sional (Corbett et al., 2005; Sandfort & Pleasant, 2009). When asked where they would prefer to
obtain information about sexual health, students overwhelming listed family physicians and gy-
necologists (Sandfort & Pleasant, 2009; Corbett et al., 2005). Therefore, there is a need to bridge
this gap in where our students get their information on healthy sex and relationships.

The problem with getting information from informal sources such as friends, the internet,
television and other media is that they can be biased, inaccurate, or incomplete and may portray
risky behaviors such as unprotected sex, physical aggression, smoking, and drinking as thrilling
and risk free (Corbett et al., 2009; Brown & Witherspoon, 2002). In addition, negative media mes-
sages may contribute to risky behaviors such as the decreased use of emergency contraception
among college students who are at the highest risk of experiencing an unplanned pregnancy (Cor-
bett et al., 2009).

However, formal sources of sexual health information are not perfect either. Some health
care providers don’t possess adequate knowledge about sexual health. One study found that only
56% of health care providers in a university medical department could correctly identify the mode
of action of different types of contraception (Wallace et al., 2004). How are college students going
to become educated if it is so difficult to find dependable information?

Several approaches have been attempted to disseminate information on sexual health to

college students. Peer health education (PHE) is a method used to promote healthy behaviors at
colleges all over the United States. PHE programs are designed to train students to teach health in-
formation, lead discussions, share values and opinions, and encourage reflection on health topics
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with their same aged peers. A recent program evaluation study at the University of California,
Santa Barbara found that PHE was an effective way of improving nutrition and drug use, but not
an effective way of improving sexual health behaviors among students (White et al., 2009).

Another type of sexual health intervention was implemented at the University of Missouri,
Kansas City. The intervention known as F.O.R.E.play (or F = Facts, O = Open Communication, R =
Responsibility, and E = Enjoyment) was based on an Information-Motivation-Behavior Skills
Model. Researchers evaluated three manners of information dissemination. Group one watched a
video with a couple discussing sex and relationships, participated in a guided class discussion, and
observed a demonstration about condoms. Group two listened to a lecture with a PowerPoint and
watched a condom demonstration. Group three was instructed to visit at least 3 of a list of 10 sex-
ual health websites. Groups one and two showed statistically significant improvement in sexual
health knowledge, whereas group three did not. This suggests that the most effective way to dis-
seminate sexual health information to college students is an in-person intervention with an in-
structor guiding the learning process (Moore et al., 2012).

Lastly, Lawrence and Fortenberry (2007) indicate that the Fear-Drive Model assists in edu-
cating, redesign behaviors and attitudes, to help modify what is considered to be the social norms,
and to promote healthy sexual behavior by generating a discomfort that will motivate the reduc-
tion of this unpleasant feeling. These previous studies helped shape the message design of this
presented outreach program.

the Men’s health initiative’s sexual and Relationship health outreach to college-age students

The Men’s Health Initiative (MHI) was founded in 2010 to promote healthy behaviors
through three primary approaches: informing men about health and wellness, identifying risks
unique to men, and implementing behavioral interventions. By offering men’s health advocacy in-
formation and promotional services regionally and nationally, MHI aims to reduce the health dis-
parity between the sexes and promote awareness and action among males.

As part of its community-based, grassroots effort, MHI has implemented initiatives to

reach out to the college male population to promote men’s health issues and bring about a general
discussion on healthy lifestyles and overall wellness, including sexual health and relationship vi-
tality. MHI’s university outreach efforts center upon relaxed, formal seminars forged with ele-
ments of the Fear-Drive Model and the Theory of Planned Behavior to serve as a message medium
to both men and women. This project’s goal was to learn lessons from a tailored message on sexual
and relationship health.

The main idea of the forum was to provide sexual and relationship health information in
innovative ways to assist informing men of risks involved with sex and relationships. As opposed
to a “fact and myth” point of view with an overload of statistics, gory pictures, and overview of
what you should and should not be doing, the seminar was given from a relationship perspective
in hopes of using scenarios and stories that the students could personally relate to while commu-
nicating sexual health information.

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The following topics were discussed: what men’s health is, what are some major sexual
health issues affecting male populations today, what can be done to help increase a healthy
lifestyle among men as it pertains to relationship-building and safe sex, and the importance of dis-
cussion among men with their physician, family, friends, and sexual partners on health and well-
ness topics (condom use and objectification of sexual partners, in particular). The goal was to
facilitate discussion among the college male population on the influence of stigmatized gender
roles and its role on sexuality, courting, relationship building, and ultimately, sexual health.

Approximately 225 university students were in attendance. Men and women attendees
were encouraged to speak freely on what sexual health, relationships, and wellness meant to them,
how they approach relationships, the role of being a man in society, and how men may contribute
to a healthy relationship. A multimedia presentation designed with Fear Drive Model and Theory
of Planned Behavior elements, including a slideshow of designed messages, helped steer the flow
of communication and provided the audience with information and graphics on the given topic.
We aimed to determine participant student reception of sexual health and relationship informa-
tion delivered with ‘fear’ and ‘subjective norms’ as the communication conduit. In other words, we
set out to determine how receptive college men would be to a sex and relationship conversation in
a public forum that was rooted in a message portraying maladaptive behaviors as high risk both
physically and emotionally.

Finally, we aimed to determine the effectiveness of fostering a rich discussion with both
men and women in the audience by highlighting peer narratives on maladaptive behaviors and the
damage caused by potential reckless behaviors. We wanted to highlight the fact that when college
students hear other students of both sexes discuss their status and thoughts on sex and relation-
ships, adverse sexual behaviors and opinions of sexual expectations of partners could be ad-
dressed, and possibly assuaged. In other words, possible maladaptive normative beliefs of college
students surrounding sexual and relationship health could be transformed to adaptive when ex-
posed to peer testimony on fears, pleasures, experiences, and items of concern.

lessons learned

A voluntary response form was available for students to fill out before and after the semi-
nar to give their opinions on sex/relationships and the session itself. Out of the 130 students who
completed the response forms, 43 were men (33%) and 87 were women (67%). The age range of
participants was from 18 to 50 years old. Three-fourths of the students fell between the ages of 20
and 23, with the average age being 22. Eighty-five percent of the participants had either a junior or
senior class standing. In terms of race, 47.7% were Caucasian, 18.5% were Hispanic, 17.7% were
African American, 6.9% were Asian, 3.1% were biracial or multiracial, and the remaining 6.1% re-
ported being another race that was not listed.

The pre-seminar response forms suggested that approximately 80% of attendees were sex-
ually active with nearly 41% never tested for STDs (50% of males and 30% of females) and 45% re-
porting that they engage in risky sexual behavior (56% of males and 40% of females). Risky sexual
behavior was defined as having sex without protection or sleeping with multiple partners simulta-
neously. When asked about condoms, 69% of students reported inconsistent use of condoms with
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26% of those students never using condoms. These percentages are more positive than what has
previously been reported by the American College Health Association (ACHA) in 2006 who found
that 82% of students inconsistently use condoms and 33% percent never use condoms. Only 5%
of males and 8% of females reported having contracted an STD at least once in their lifetime. This
statistic is comparable to and possibly better than a similar finding by the ACHA (2009) that 3.3%
of males and 5.7% of females had contracted an STD in the last year alone.

When it comes to questions on perceived risk and sexual health knowledge, our students
seemed to score better than what has previously been reported (Stanford & Pleasant, 2009; Car-
rera et. al, 2000). Surprisingly, 61% of males and 53% of females overestimated the number of
cases of Chlamydia per 100,000 people in Florida, indicating that students’ perceived risk of con-
tracting an STD might be higher than previously assumed (Sandfort & Pleasant, 2009).

The post-seminar response forms showed that approximately 71% of the respondents (67%
of males and 72% of females) have been in an unhealthy relationship (self-defined). A majority of
those students (56% of males and 77% of females) claimed that the unhealthy relationship was
more their partner’s fault than their own. The post-seminar response forms also suggested that as
a result of the seminar, students’ views about sexual health had changed and they were willing to
change their sexual behavior for the better. Almost 100% of students believed it was necessary to
be tested for STDs when sexually active with multiple partners. Additionally, students overwhelm-
ingly (93% of males and 100% of females) indicated that they will be more vigilant about wearing a
condom while engaging in sexual activities when under the influence of alcohol. Additionally,
95% reported they will be more judicious when selecting sexual partners (91% of males and 97%
of females) and more apt to pursue STD testing (95% of both males and females).

Response forms also suggested that a seminar-style of health information delivery is ac-
ceptable and maybe even be preferred by both male and female college students. Approximately
72% of the attendees(68% of males and 75% of females) stated that they will absolutely attend
similar seminars in the future and if we add those who stated they might attend similar seminars
in the future, the statistic rises to 97% (95% of males and 98% of females). This lends credence to
the theoretical design of the messages delivered, both in the slideshow and the oral expression of
thought.

After the seminar was over, students were given a chance to individually reflect on the top-
ics covered. A total of 88 students (22 males and 66 females) shared their thoughts and several
trends were discovered aloud amongst the audience. Students were not directly asked questions or
otherwise prompted on what to say during their reflection. If they wanted to continue sharing,
they were encouraged.

Out of the 88 students who participated in reflection, approximately 83% brought up the
overall success of the seminar. Above all, the students enjoyed the interactive nature of the discus-
sion as it gave them an opportunity to freely voice their opinions and personal experiences as op-
posed to the hierarchical, top-down, lecture-style approach, which may discourage
experience-sharing. Many mentioned that it was nice to hear other students’ perspectives. A few
male members of the audience mentioned that even though the lecture was geared toward men,
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they were glad that women were in attendance because they added a different viewpoint to the
discussion.

Students appreciated that the tone was light-hearted and humorous at some points and
serious and enlightening at other points. Many students indicated that they appreciated how the
presenter was vulnerable and admitted that he had made mistakes in his past relationships. They
also liked that the talk was not just about STDs, but that it also covered a wide range of topics that
are considered taboo in an educational environment.

Just over 65% of the students admitted that they had learned something new during the
seminar (77% of males and 65% of females). Many confessed that they did not know how preva-
lent STDs were in Central Florida. Students also mentioned that they were astounded by how
many unplanned pregnancies happened while women were under the influence alcohol. They
were also shocked about the costs associated with having a baby. Others were surprised at how
many men and women in monogamous relationships cheat on their partner. Many students also
mentioned a change in their perceptions about the opposite sex. A few students mentioned that
most of what they heard during the seminar confirmed their previous assumptions. Even those
who claimed that they already knew everything covered in the discussion had good things to say
about it. They said it was good to hear again at an older age when the information was more rele-
vant and when they were mature enough to take it seriously, which is important for education
where repetition may reinforce the learning process.

A little over two-thirds of the students (68%) discussed relationships and how they real-
ized that media had given them unrealistic expectations about how their partners should act.
They stated that these misperceptions were probably the root of their relationship problems.
Women revealed that the discussion about idealized, romanticized notions of men and women
opened their eyes to the fact that they should not be using fairy tale- or ‘chick flick’- stereotyped
men to set their criteria for a good man. Men mentioned that the discussion on pornography
brought them to the realization that it was not reasonable to expect their woman to look act in a
sexually-suggestive, permissive role as idealized in popular media.

About 13% of students (5% of males and 15% of females) who participated in the reflection
said they would share the information they learned with their friends and family members.
Twenty-seven percent of males and 15% of females mentioned that they would immediately
change their behaviors in regards to relationships and sexual health. Roughly 40% of students
(41% of males and 38% of females) said they were curious to know the results of the pre and post-
seminar response forms and that they enjoyed themselves so much that they were looking forward
to future seminars.

discussion

MHI’s seminar and its health relationship perspective was used as an attempt to explore
the culture of sexual health and how sexuality and gender conformity has normalized among the
college population. We aimed to support sexuality as opposed to criminalizing it. The seminar
gave students the opportunity to not only share personal experiences but also to hear and learn
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about what really their peers are doing and what sex meant to others. This gave students a better
perspective on the issue around them, especially for those who overestimated and/or underesti-
mated what their peers were doing. The power of peer perception allowed students to reflect on
their individual expectations in themselves and their relationships.

The medium we used allowed students to reflect on their own experiences (the power of
autonomy) and examine their own relationship and sexual values in hopes of making connections
with what they ideally want. The use of scenarios on subjective norms of sex and relationships
(The Notebook and Maxim/Playboy magazine) to create alternative realities for sexual health (be-
yond the expectations from these movies and magazines), was discussed as creating false expecta-
tions about intimacy. The sense of ownership of their current state of sexual health and
relationships, when defined in the light of the aforementioned mediums, was evident in terms of
their claimed responsibility in possibly adopting maladaptive behaviors and/or contributing to
failed relationships. In fact, one of the most receptive pieces of the seminar was the advice given
towards keeping a happy and healthy relationship: It takes two people who genuinely want to be
with each other to “make it work” as opposed to advice on having safe sex and what not do to,
which is what they are previously accustomed to. The norm has been to lecture on safe sex as op-
posed to a focus on the relationship aspect of courtship. Perhaps that is what is causing the break-
down of adaptive sexual health behaviors? Perhaps the objectification of sexual health into
specific anatomy lessons is undergirding the problem? As seen by the feedback on this seminar,
we believe discussions on relationship-building are essential for true success.

The style of an unorthodox, non-lecture format raised the attention of the audience. This
style requires a certain “facilitator” to actively engage the audience. However, we acknowledge that
this may be a problem too where engaging the speaker to talk about some of their experiences
might be embarrassing and have the opposite effect of what we are trying to achieve. However, we
only chose those volunteers to share their experiences aloud. We were sure to preserve the tone of
the discussion where the audience was free to voice opinions or experiences without the sense of
feeling judged by integrating personal and related stories.

It is clear from MHI’s relationship and sexual health seminar that there is a need for more
forums where college-aged men can comfortably engage in topics that can help increase their
awareness of risky sexual practices and improve their overall sexual hygiene. The discussions we
had clearly supported previous research on knowledge and awareness of sex and relationship
health among this population.

College male students should be specifically targeted by health professionals to promote

healthy sexual and romantic relationships. The issue is not that we need to do more, but that we
need to try something new. This approach should make it more personable and much more relat-
able. So why not use relationships and expectations? The qualitative lessons learned demon-
strated are sufficient and necessary to lay the foundations for larger, more in-depth analyses on
the use of such seminars to promote sexual and relationship health and wellness issues among
college students populations. As we think of developing interventions for college men, and men in
general, consideration needs to be given to the systemic issues that serve as barriers for men to ac-
cess health services. Social and behavioral explanations alone only serves to pathologize and
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stereotype men while disregarding the multilevel forces that contribute to gendered health dispar-
ities. In addition to providing education to promote healthy sexual practices, future research
should explore the ways in which the health care system, including campus health centers, can
better engage males in order to close the gap in gender-based health inequalities.

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Michael J. Rovito is an Instructor in the Department of Health Professions at the

University of Central Florida. His work specializes in health behavior change,
men's health, and audience segmentation. He may be reached at
[email protected] or [email protected].

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