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Dating practices : the influence of context and the gendered nature of heterosexual relationships on… Masaro, Cindy Louise 2014

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	  	   DATING	  PRACTICES:	  THE	  INFLUENCE	  OF	  CONTEXT	  AND	  THE	  GENDERED	  NATURE	  OF	  HETEROSEXUAL	  RELATIONSHIPS	  ON	  WOMEN’S	  SEXUAL	  WELL-­‐BEING	  	  by	  	  Cindy	  Louise	  Masaro	  B.S.N.,	  The	  University	  of	  British	  Columbia,	  2000	  M.S.N.,	  The	  University	  of	  British	  Columbia,	  2005	  	  A	  THESIS	  SUBMITTED	  IN	  PARTIAL	  FULFILLMENT	  OF	  THE	  REQUIREMENTS	  FOR	  THE	  DEGREE	  OF	  	  	  DOCTOR	  OF	  PHILOSOPHY	  in	  THE	  FACULTY	  OF	  GRADUATE	  AND	  POSTDOCTORAL	  STUDIES	  (Nursing)	  	  THE	  UNIVERSITY	  OF	  BRITISH	  COLUMBIA	  (Vancouver)	  	  December	  2014	  ©	  Cindy	  Louise	  Masaro,	  2014	  ii	  	  Abstract	  Limited	  attention	  has	  been	  paid	  to	  adult	  women’s	  sexual	  well-­‐being	  despite	  their	  steadily	  rising	  rates	  of	  sexually-­‐transmitted	  infections	  (STI)	  and	  human	  immunodeficiency	  virus	  (HIV).	  Two	  understudied	  areas	  that	  may	  affect	  women's	  sexual	  well-­‐being	  are	  the	  changing	  context	  of	  dating	  and	  the	  gendered	  nature	  of	  heterosexual	  relationships.	  Internet	  technologies	  have	  become	  popular,	  yet	  little	  is	  known	  about	  how	  these	  technologies	  influence	  women's	  sexual	  risk.	  	  Additionally,	  few	  studies	  have	  addressed	  how	  conformity	  to	  gendered	  norms	  related	  to	  sexual	  activity	  and	  the	  expression	  of	  pleasure	  (i.e.,	  orgasm	  during	  sex)	  influence	  women's	  sexual	  risk	  and	  well-­‐being.	  	   	  Analyses	  were	  undertaken	  of	  data	  collected	  from	  an	  online	  survey	  of	  1,266	  adult	  women	  living	  in	  the	  United	  States.	  Two	  models	  of	  sexual	  risk	  were	  hypothesized	  with	  associations	  between:	  (a)	  the	  modality	  and	  time	  spent	  communicating,	  the	  motivations	  and	  the	  pressure	  for	  sexual	  activity,	  and	  sexual	  risk	  and	  (b)	  sexual	  self-­‐disclosure	  and	  communication	  about	  sexual	  risk.	  Multinomial	  logistic	  regression	  was	  used	  for	  the	  analyses.	  A	  third	  model	  examined	  women's	  sexual	  well-­‐being	  in	  terms	  of	  faking	  orgasm.	  Binary	  logistic	  regression	  was	  used	  to	  examine	  predictors	  of	  faking	  orgasm	  including	  the	  importance	  of,	  and	  pressure	  to	  achieve	  orgasm,	  and	  the	  frequency	  of,	  and	  satisfaction	  with,	  orgasm.	  	  	  Neither	  the	  modality	  nor	  time	  spent	  communicating	  was	  associated	  with	  sexual	  risk,	  however,	  the	  expectation	  to	  communicate	  trust	  and	  adherence	  to	  sexual	  scripts	  were	  associated.	  Discussion	  about	  past	  sexual	  behaviour	  (e.g.,	  sexual	  positions,	  experiences)	  increased	  risk;	  yet,	  communication	  about	  STIs	  and	  HIV	  did	  not.	  The	  majority	  of	  women	  reported	  that	  they	  had	  faked	  orgasm	  during	  penile-­‐vaginal	  intercourse.	  Perceived	  pressure	  to	  achieve	  an	  orgasm	  during	  this	  activity	  predicted	  the	  faking	  of	  orgasm.	  	  	  iii	  	  The	  findings	  of	  this	  study	  indicate	  that	  women's	  sexual	  risk	  does	  not	  appear	  to	  be	  influenced	  by	  how	  they	  meet	  partners	  or	  by	  the	  modality	  and	  time	  spent	  communicating.	  Communication	  about	  STIs	  and	  HIV,	  does	  appear	  to	  decrease	  sexual	  risk.	  The	  gendered	  nature	  of	  heterosexual	  relationships	  is	  of	  particular	  importance	  for	  women's	  sexual	  well-­‐being.	  Given	  the	  results	  of	  this	  study,	  women	  conforming	  to	  gendered	  expectations	  about	  sex	  are	  less	  likely	  to	  express	  what	  they	  find	  sexually	  pleasing.	  	  	  iv	  	  	   Preface	  	  This	  doctoral	  dissertation	  is	  the	  original,	  unpublished,	  independent	  work	  of	  the	  author,	  Cindy	  L.	  Masaro.	  The	  research	  carried	  out	  for	  this	  doctoral	  dissertation	  was	  approved	  by	  the	  University	  of	  British	  Columbia,	  Behavioural	  Research	  Ethics	  Board	  (Project	  title:	  "Exploring	  women's	  dating	  experiences:	  How	  do	  new	  ways	  of	  communicating	  affect	  intimacy	  and	  sexual	  practices	  in	  the	  digital	  era?"	  Certificate	  H10-­‐03367).	  The	  co-­‐authors	  of	  the	  manuscripts	  included	  in	  this	  dissertation	  were	  supervisory	  committee	  members:	  Dr.	  J.	  L.	  Johnson,	  Dr.	  P.	  A.	  Ratner,	  Dr.	  V.	  Bungay,	  Dr.	  J.	  Buxton,	  and	  Dr.	  B.	  Zumbo.	  Chapters	  2,	  3,	  and	  4	  will	  be	  further	  developed	  for	  publication	  in	  peer-­‐reviewed	  journals	  with	  the	  following	  authors,	  in	  order:	  Cindy	  Masaro,	  Joy	  L.	  Johnson,	  Vicky	  Bungay,	  Jane	  Buxton,	  Bruno	  Zumbo,	  and	  Pamela	  A.	  Ratner.	  Cindy	  Masaro	  was	  responsible	  for	  the	  data	  collection	  and	  analysis	  and	  the	  initial	  drafts	  of	  all	  chapters.	  The	  supervisory	  committee	  offered	  advice	  with	  respect	  to	  the	  formulation	  of	  the	  research	  questions,	  data	  analysis,	  interpretation,	  and	  writing.	  v	  	  	   Table	  of	  Contents	  Abstract.................................................................................................................................. ii	  Preface ...................................................................................................................................iv	  Table	  of	  Contents ................................................................................................................... v	  List	  of	  Tables .........................................................................................................................xii	  List	  of	  Abbreviations.............................................................................................................xiv	  Chapter	  1:	  Introduction .......................................................................................................... 1	  Review	  of	  the	  Literature...................................................................................................... 4	  The	  context	  of	  dating	  in	  the	  digital	  era. ..................................................................................5	  Computer-­‐mediated	  versus	  face-­‐to-­‐face	  communication. .....................................................7	  HIV	  rates	  in	  adult	  women......................................................................................................12	  Sexual	  risk. ............................................................................................................................16	  Why	  study	  heterosexual	  women's	  sexual	  risk?.....................................................................18	  Traditional	  sexual	  scripts. ..................................................................................................18	  Women's	  orgasm	  and	  conformity	  with	  sexual	  scripts. ......................................................21	  Summary .......................................................................................................................... 22	  Chapter	  2:	  Theoretical	  and	  Methodological	  Approach .......................................................... 25	  Theoretical	  Models	  and	  Hypotheses ................................................................................. 25	  Conceptual	  Definitions...................................................................................................... 28	  vi	  	  Purpose	  and	  Study	  Objectives ........................................................................................... 30	  Research	  Approach ........................................................................................................... 30	  The	  Measurement	  of	  Key	  Variables................................................................................... 33	  Sociodemographic	  and	  sexual	  risk	  factors. ...........................................................................33	  Meeting	  modality..................................................................................................................34	  Time	  spent	  communicating	  with	  partners. ...........................................................................35	  Total	  number	  of	  hours	  spent	  in	  online	  communication	  per	  week......................................35	  Total	  number	  of	  hours	  spent	  in	  face-­‐to-­‐face	  communication	  per	  week. ...........................35	  Sexual	  pressure. ....................................................................................................................35	  Sexual	  motivations. ...............................................................................................................37	  Sexual	  self-­‐disclosure. ...........................................................................................................38	  Safer	  sex	  communication. .....................................................................................................39	  Orgasm. .................................................................................................................................40	  Importance	  of	  and	  pressure	  to	  achieve	  orgasm. ..................................................................41	  The	  Measurement	  of	  the	  Outcome	  Variables .................................................................... 42	  Sexual	  risk. ............................................................................................................................42	  Ever	  faked	  orgasm.................................................................................................................43	  Pilot	  Testing ...................................................................................................................... 44	  Data	  Analysis .................................................................................................................... 44	  Data	  preparation...................................................................................................................45	  Examination	  of	  missing	  data. ................................................................................................45	  vii	  	  Confirmatory	  factor	  analysis. ................................................................................................46	  Method	  of	  estimation. ..........................................................................................................46	  Model	  fit................................................................................................................................47	  Evaluating	  measurement	  validity..........................................................................................47	  Sexual	  motivations. ...........................................................................................................47	  Sexual	  pressure. .................................................................................................................50	  Exploratory	  factor	  analysis. ...................................................................................................52	  Model	  evaluation. .................................................................................................................52	  Method	  of	  estimation. ..........................................................................................................52	  Model	  fit	  for	  the	  exploratory	  factor	  analyses. ......................................................................52	  Evaluating	  measurement	  validity..........................................................................................53	  Safer	  sex	  communication...................................................................................................53	  Sexual	  self-­‐disclosure.........................................................................................................55	  Regression	  analyses. .............................................................................................................57	  Recoded	  variables. ................................................................................................................59	  Organization	  of	  the	  Dissertation ....................................................................................... 61	  Chapter	  3:	  Adult	  Women's	  Sexual	  Risk:	  The	  Influence	  of	  Communication,	  Motivation,	  and	  Pressure	  for	  Sex.................................................................................................................... 62	  Introduction...................................................................................................................... 62	  Review	  of	  the	  Literature.................................................................................................... 64	  Motivations	  for	  sex	  and	  pressure	  to	  engage	  in	  sex...............................................................64	  viii	  	  Methods ........................................................................................................................... 68	  Study	  design. .........................................................................................................................68	  Sample...................................................................................................................................68	  Data	  collection. .....................................................................................................................69	  Measures...............................................................................................................................69	  Sociodemographic	  characteristics	  and	  sexual	  risk	  factors.................................................69	  Meeting	  modality	  and	  time	  spent	  communicating	  with	  partners. ....................................70	  Sexual	  pressure. .................................................................................................................71	  Sexual	  motivations. ...........................................................................................................72	  Sexual	  risk. .........................................................................................................................72	  Data	  analysis. ........................................................................................................................73	  Results .............................................................................................................................. 74	  Demographic	  characteristics.................................................................................................74	  Sexual	  risk	  factors	  and	  reasons	  for	  dating. ...........................................................................76	  Types	  of	  communication.......................................................................................................77	  Sexual	  risk. ............................................................................................................................79	  Multinomial	  logistic	  regression	  models. ...............................................................................80	  Discussion ......................................................................................................................... 88	  Conclusion ........................................................................................................................ 94	  Chapter	  4:	  Communication	  about	  Sexual	  Practices:	  	  Does	  it	  Influence	  Sexual	  Risk? .............. 96	  	  Introduction...................................................................................................................... 96	  ix	  	  Methods ..........................................................................................................................103	  Study	  design. .......................................................................................................................103	  Sample.................................................................................................................................103	  Data	  collection. ...................................................................................................................104	  Measures.............................................................................................................................104	  Sociodemographic	  characteristics	  and	  sexual	  risk	  factors...............................................104	  Meeting	  modality	  and	  time	  spent	  communicating	  with	  partners. ..................................105	  Sexual	  self-­‐disclosure.......................................................................................................106	  Safer	  sex	  communication.................................................................................................106	  Data	  analysis. ......................................................................................................................107	  Results .............................................................................................................................108	  Multinomial	  logistic	  regression	  models. .............................................................................109	  Discussion ........................................................................................................................116	  Chapter	  5:	  Do	  Gendered	  Sexual	  Scripts	  Influence	  Whether	  Women	  Fake	  Orgasm?..............121	  Introduction.....................................................................................................................121	  Methods ..........................................................................................................................126	  Study	  design. .......................................................................................................................126	  Sample	  and	  data	  collection. ................................................................................................126	  Measures.............................................................................................................................127	  Age	  	  and	  number	  of	  sexual	  partners	  in	  the	  last	  year. ......................................................127	  Orgasm. ...........................................................................................................................127	  x	  	  Importance	  of	  and	  pressure	  to	  achieve	  orgasm. .............................................................128	  Ever	  faked	  an	  orgasm. .....................................................................................................129	  Analyses. .............................................................................................................................129	  Results .............................................................................................................................130	  Descriptive	  statistics	  of	  orgasm	  occurrence,	  satisfaction,	  and	  faking	  orgasms. .................130	  Frequency	  of	  Orgasm...........................................................................................................132	  Logistic	  regression	  analysis. ................................................................................................132	  Discussion ........................................................................................................................134	  Limitations	  and	  Implications ............................................................................................138	  Chapter	  6:	  Conclusion..........................................................................................................140	  Summary	  of	  Findings........................................................................................................140	  Unique	  Contributions.......................................................................................................143	  Limitations.......................................................................................................................145	  Implications .....................................................................................................................147	  Conclusion .......................................................................................................................149	  References ..........................................................................................................................150	  Appendices..........................................................................................................................181	  Appendix	  A:	  Study	  Questionnaire.....................................................................................181	  Appendix	  B:	  Confirmatory	  Factor	  Analysis	  Flow	  Chart ......................................................202	  xi	  	  Appendix	  C:	  Exploratory	  Factor	  Analysis	  Flow	  Chart.........................................................203	  xii	  	  	   List	  of	  Tables	  Table	  2.1	  Results	  of	  the	  Confirmatory	  Factor	  Analysis	  of	  the	  Sexual	  Motivations	  Measure ..................... 49	  Table	  2.2	  Results	  of	  the	  Confirmatory	  Factor	  Analysis	  of	  the	  Sexual	  Pressure	  Measure .......................... 51	  Table	  2.3	  Results	  of	  the	  Exploratory	  Factor	  Analysis	  of	  the	  Safer	  Sex	  Communication	  Measure ............. 55	  Table	  2.4	  Results	  of	  the	  Exploratory	  Factor	  Analysis	  of	  the	  Sexual	  Self-­‐Disclosure	  Measure.................... 57	  Table	  2.5	  Frequency	  Distribution	  of	  the	  Duration	  of	  Computer-­‐Mediated	  and	  Face-­‐to-­‐Face	  Communication,	  Age	  at	  First	  Sexual	  Intercourse,	  Number	  of	  Sexual	  Partners,	  and	  Sexual	  Risk	  Scores.... 60	  Table	  3.1	  Sample	  Demographics................................................................................................................ 75	  Table	  3.2	  Sexual	  Risk	  and	  Reasons	  for	  Dating............................................................................................ 77	  Table	  3.3	  Type	  and	  Frequency	  of	  Communication	  with	  Sexual	  Partner .................................................... 78	  Table	  3.4	  Descriptive	  Statistics	  of	  the	  Sexual	  Motivations	  and	  Sexual	  Pressure	  Subscales....................... 79	  Table	  3.5	  Frequency	  Distribution	  of	  the	  Sexual	  Risk	  Scores ...................................................................... 79	  Table	  3.6	  Model	  1—Sexual	  Risk	  Regressed	  on	  all	  Predictors:	  Model	  Fit ................................................... 80	  Table	  3.7	  Full	  Model	  1—Sexual	  Risk	  Regressed	  on	  21	  Predictors:	  Likelihood	  Ratio	  Tests......................... 81	  Table	  3.8	  Final	  Model—Sexual	  Risk	  Regressed	  on	  Statistically	  Significant	  Predictors:	  Model	  Fit ............. 82	  Table	  3.9	  Final	  Model—Sexual	  Risk	  Regressed	  on	  Statistically	  Significant	  Predictors:	  Likelihood	  Ratio	  Tests........................................................................................................................................................... 83	  Table	  3.10	  Final	  Model—Sexual	  Risk	  Regressed	  on	  Statistically	  Significant	  Predictors:	  Parameter	  Estimates ................................................................................................................................................... 84	  Table	  3.11	  Overall	  Percentage	  Accuracy	  Rate	  of	  Final	  Model ................................................................... 87	  Table	  3.12	  Differences	  in	  Means	  of	  Show	  Trust,	  Women’s	  Sex	  Role,	  and	  Peer	  Pressure	  Motives	  of	  Correctly	  Classified	  High-­‐Risk	  Group	  and	  All	  Other	  Participants ............................................................... 87	  Table	  4.1	  Descriptive	  Statistics	  of	  Safer	  Sex	  Communication	  and	  the	  Sexual	  Self-­‐Disclosure	  Subscales. 109	  xiii	  	  Table	  4.2	  Model	  1—Sexual	  Risk	  Regressed	  on	  all	  Predictors:	  Model	  Fit ................................................. 110	  Table	  4.3	  Model	  1—Sexual	  Risk	  Regressed	  on	  all	  Predictors:	  Likelihood	  Ratio	  Tests.............................. 111	  Table	  4.4	  Final	  Model—Sexual	  Risk	  Regressed	  on	  Statistically	  Significant	  Predictors:	  Model	  Fit ........... 112	  Table	  4.5	  Final	  Model—Sexual	  Risk	  Regressed	  on	  Statistically	  Significant	  Predictors:	  Likelihood	  Ratio	  Tests......................................................................................................................................................... 112	  Table	  4.6	  Final	  Model—Sexual	  Risk	  Regressed	  on	  Statistically	  Significant	  Predictors:	  	  Parameter	  Estimates ................................................................................................................................................. 113	  Table	  4.7	  Comparison	  of	  Means	  of	  Correctly	  Classified	  High	  Sexual	  Risk	  Group	  and	  All	  Other	  Participants................................................................................................................................................................. 115	  Table	  5.1	  Descriptive	  Statistics—Occurrence,	  Satisfaction,	  and	  Faking	  an	  Orgasm	  during	  Penile-­‐Vaginal	  Intercourse............................................................................................................................................... 131	  Table	  5.2	  Frequency	  of	  Orgasm	  during	  Various	  Sexual	  Activities ............................................................ 132	  Table	  5.3	  Omnibus	  Tests	  of	  Model	  Coefficients	  of	  Logistic	  Regression	  of	  Ever	  Faked	  an	  Orgasm	  on	  Selected	  Predictors .................................................................................................................................. 133	  Table	  5.4	  Classification	  Table	  of	  Predicted	  versus	  Observed	  Cases	  of	  Ever	  Faked	  an	  Orgasm................ 133	  Table	  5.5	  Logistic	  Regression—Ever	  Faked	  an	  Orgasm............................................................................ 134	  	  xiv	  	  List	  of	  Abbreviations	  	  AMT	  	   	   Amazon	  mechanical	  turk	  CFA	   	   Confirmatory	  factor	  analysis	  CM	   	   Coping	  Motives	  Scale	  CMC	   	   Computer-­‐mediated	  communication	  COS	   	   Coital	  Orgasm	  Questionnaire	  EFA	   	   Exploratory	  factor	  analysis	  EM	   	   Enhancement	  Motives	  Scale	  FOS	   	   Female	  Orgasm	  Questionnaire	  FTF	  	   	   Face-­‐to-­‐face	  communication	  HIV	  	   	   Human	  immunodeficiency	  virus	  ID	   	   Identification	  number	  IM	   	   Intimacy	  Motives	  Scale	  LR	   	   Binary	  logistic	  regression	  LRT	   	   Log-­‐likelihood	  ratio	  test	  MLR	   	   Multinomial	  logistic	  regression	  MSM	   	   Men	  who	  have	  sex	  with	  men	  PA	   	   Parallel	  analysis	  PAM	   	   Partner	  Approval	  Motives	  Scale	  PCA	   	   Principal	  Components	  Analysis	  PPM	   	   Peer	  Pressure	  Motives	  Scale	  PVI	   	   Penile	  vaginal	  intercourse	  SAM	   	   Self-­‐Affirmation	  Motives	  Scale	  xv	  	  SEM	   	   Structural	  equation	  modelling	  SIP	   	   Social	  Information	  Processing	  Theory	  SPSW	  –	  R	   Sexual	  Pressure	  Scale	  for	  Women	  –	  Revised	  SPT	   	   Social	  Presence	  Theory	  SMS	   	   Sexual	  Motives	  Scale	  RML	   	   Robust	  maximum	  likelihood	  RMSEA	   	   Root	  mean	  square	  error	  of	  approximation	  SSDS	  	   	   Sexual	  Self-­‐Disclosure	  Scale	  	  STI	  	   	   Sexually	  transmitted	  infection	  URAI	   	   Unprotected	  receptive	  anal-­‐intercourse	  WLSMV	  	   Weighted	  least	  squares	  estimation,	  mean	  and	  variance	  adjusted	  	  1	  	  Chapter	  1:	  Introduction	  	  Epidemiological	  studies	  indicate	  that	  sexually	  transmitted	  infections	  (STIs)	  and	  human	  immunodeficiency	  virus	  (HIV)	  rates	  are	  rising	  faster	  in	  women	  25	  years	  of	  age	  and	  older	  than	  in	  their	  younger	  counterparts	  (Centers	  for	  Disease	  Control	  and	  Prevention,	  2013a,	  2014).	  Despite	  these	  increasing	  rates	  in	  this	  group	  of	  adult	  women,	  little	  is	  known	  about	  their	  sexual	  practices	  and	  how	  they	  impact	  their	  overall	  sexual	  well-­‐being.	  Sexual	  well-­‐being	  "involves	  positive	  self	  expression,	  coupled	  with	  the	  possibility	  of	  satisfying	  and	  safe	  sexual	  experiences"	  (Scott-­‐Sheldon,	  Kalichman,	  &	  Carey,	  2010,	  p.	  59).	  1	  This	  dissertation	  focuses	  on	  sexual	  well-­‐being,	  specifically	  sexual	  risk	  in	  terms	  of	  HIV	  transmission	  and	  sexual	  pleasure	  in	  relation	  to	  orgasm.	  Sexual	  risk	  refers	  to	  a	  lack	  of	  protection,	  such	  as	  the	  failure	  to	  use	  a	  barrier	  method	  to	  prevent	  the	  transmission	  of	  HIV,	  as	  well	  as	  sexual	  activities	  that	  place	  women	  at	  a	  greater	  risk	  of	  HIV	  transmission.	  The	  first	  area	  of	  focus	  of	  this	  dissertation	  considers	  sexual	  activities	  that	  vary	  in	  terms	  of	  their	  level	  of	  risk	  for	  HIV	  transmission	  and	  examines	  factors	  that	  may	  influence	  women’s	  decisions	  about	  engaging	  in	  these	  activities.	  The	  second	  area	  of	  focus	  considers	  the	  gendered	  nature	  of	  heterosexual	  relationships2	  and	  how	  factors	  related	  to	  conventions	  of	  heterosexuality	  may	  affect	  women’s	  sexual	  risk	  as	  well	  as	  their	  expression	  of	  sexual	  pleasure.	  The	  factors	  considered	  in	  the	  first	  area	  of	  focus	  concern	  the	  changing	  context	  of	  dating,	  namely,	  dating	  in	  the	  “digital	  era”	  and	  the	  existence	  of	  digital	  technology.	  Internet	  usage,	  which	  has	  tripled	  in	  the	  last	  decade,	  has	  revolutionized	  how	  people	  interact	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  1 Safe	  sexual	  experiences	  refers	  to	  engaging	  in	  sexual	  activities	  or	  practices	  that	  are	  the	  least	  likely	  to	  transmit	  an	  STI	  or	  HIV.	  	  2	  The	  gendered	  nature	  of	  heterosexual	  relationships	  refers	  to	  inequalities	  between	  men	  and	  women	  in	  terms	  of	  power,	  control,	  wealth	  and	  social	  status.	  Men	  are	  routinely	  accorded	  more	  power,	  control,	  and	  agency	  than	  women,	  men's	  interests	  are	  usually	  privileged	  over	  women's,	  and	  men	  benefit	  routinely	  from	  a	  number	  of	  material	  advantages	  not	  similarly	  available	  to	  women	  (Baker	  &	  Elizabeth,	  2013).	  Baker	  and	  Elizabeth	  contend	  that	  in	  such	  contexts,	  women	  frequently	  adhere	  to	  gendered	  "rules	  of	  the	  game"	  to	  secure	  access	  to	  economic	  resources	  or	  to	  elevate	  their	  social	  status.	   2	  	  and	  communicate	  with	  each	  other;	  it	  is	  not	  surprising,	  then,	  that	  internet	  technologies	  are	  increasingly	  used	  to	  establish	  and	  maintain	  relationships	  with	  others,	  a	  process	  that	  is	  commonly	  referred	  to	  as	  computer-­‐mediated	  communication	  (CMC).3	  Research	  evidence	  suggests	  that	  people,	  particularly	  adult	  women,	  are	  using	  CMC	  to	  find	  and	  maintain	  relationships	  with	  romantic	  and	  sexual	  partners,	  and	  that	  they	  are	  engaging	  in	  more	  risky	  sexual	  behaviour	  than	  those	  who	  meet	  their	  partners	  in	  more	  traditional,	  face-­‐to-­‐face	  (FTF)	  settings	  (Couch	  &	  Liamputtong,	  2008;	  McWilliams	  &	  Barrett,	  2014;	  Padgett,	  2007).	  Yet,	  despite	  the	  popularity	  of	  CMC,	  research	  is	  lacking	  on	  how	  CMC	  affects	  women’s	  sexual	  risk	  as	  they	  search	  for	  potential	  partners.	  	  	   The	  factors	  considered	  in	  the	  dissertation’s	  second	  area	  of	  focus	  relate	  to	  gender	  roles	  in	  terms	  of	  gendered	  sexual	  scripts4	  and	  the	  power	  differential	  that	  exists	  between	  men	  and	  women.	  Although	  these	  factors	  have	  been	  acknowledged	  as	  influential	  in	  women’s	  sexual	  decision	  making	  (Wingood	  &	  DiClemente,	  2000),	  little	  is	  known	  about	  how	  these	  scripts	  influence	  adult	  women’s	  motivations	  for	  sex,	  pressure	  to	  engage	  in	  sex,	  or	  what	  they	  communicate	  to	  their	  partner	  when	  in	  a	  sexual	  encounter.	  Social	  pressure	  to	  conform	  to	  traditional	  gender	  roles	  may	  place	  women	  at	  risk	  of	  acquiring	  HIV	  because	  their	  sexual	  agency	  is	  restricted	  (Morokoff,	  2000;	  Schick,	  Zucker,	  &	  Bay-­‐Cheng,	  2008).	  For	  example,	  women	  may	  be	  less	  assertive	  in	  the	  discussion	  and	  negotiation	  of	  sexual	  practices	  that	  provide	  protection	  from	  infection	  or	  in	  discussion	  that	  allows	  them	  to	  express	  their	  sexual	  desire	  or	  pleasure,	  particularly	  in	  relation	  to	  their	  own	  orgasms.	  As	  pleasure	  is	  part	  of	  what	  most	  people	  hope	  to	  experience	  when	  they	  engage	  in	  sexual	  activity,	  examining	  pleasure	  and	  issues	  related	  to	  pleasure	  are	  important	  when	  considering	  discussions	  about	  sexual	  risk	  and	  safer	  sex.	  Safer	  sex	  and	  safer	  sexual	  practices	  are	  used	  synonymously	  in	  this	  dissertation.	  They	  refer	  to	  sexual	  activities	  that	  are	  associated	  with	  less	  risk	  of	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  3	  The	  term	  computer-­‐mediated	  communication	  (CMC)	  refers	  to	  any	  type	  of	  internet	  technology	  used	  to	  communicate	  with	  others.	  For	  this	  study	  we	  are	  examining	  written	  text,	  specifically	  email	  and	  chat/social	  networking	  discussions	  used	  to	  establish	  or	  maintain	  relationships	  with	  partners.	  4	  Gendered	  sexual	  scripts	  refer	  to	  societal	  conventions	  that	  shape	  people’s	  understanding,	  beliefs,	  and	  actions	  about	  how	  to	  behave	  in	  sexual	  situations;	  they	  consequently	  guide	  people’s	  sexual	  conduct.	  The	  terms	  gendered	  sexual	  scripts,	  traditional	  sexual	  scripts,	  and	  sexual	  scripts	  are	  used	  synonymously	  throughout	  this	  dissertation.	  3	  	  contracting	  HIV	  when	  engaging	  in	  certain	  sexual	  behaviours	  or	  practices.	  Some	  studies	  have	  shown	  that	  when	  women	  are	  denied	  the	  possibility	  of	  sexual	  pleasure	  within	  sexual	  relationships	  there	  is	  a	  negative	  impact	  on	  their	  ability	  to	  negotiate	  safer	  sexual	  practices	  (Holland,	  Ramazonoglu,	  Sharpe,	  &	  Thomson,	  1992;	  Philpott,	  Knerr,	  &	  Boydell,	  2006;	  Scott-­‐Sheldon,	  Marsh,	  Johnson,	  &	  Glasford,	  2006).	  Currently,	  there	  is	  little	  understanding	  about	  the	  ways	  in	  which	  the	  positive	  and	  pleasurable	  aspects	  of	  women's	  sexual	  experiences	  impact	  their	  sexual	  risk	  and	  consequently	  their	  sexual	  well-­‐being.	  	  	   For	  the	  most	  part,	  the	  focus	  of	  sexual	  health	  education	  programs	  has	  been	  on	  prevention,	  primarily	  condom	  use	  as	  a	  risk	  reduction	  strategy,	  and	  has	  not	  acknowledged	  other	  factors	  that	  may	  be	  influential	  in	  women’s	  decisions	  about	  sexual	  practices,	  including	  those	  considered	  to	  be	  high	  risk	  for	  HIV	  transmission.	  STI	  and	  HIV	  education	  and	  prevention	  campaigns	  traditionally	  have	  contained	  gender	  neutral	  messages,	  and	  have	  not	  targeted	  women	  specifically	  (Dworkin,	  Beckford,	  &	  Ehrhardt,	  2007).	  Over	  the	  last	  several	  years,	  with	  the	  rising	  rates	  of	  HIV	  infection	  in	  women,	  prevention	  education	  and	  intervention	  strategies	  have	  started	  to	  become	  gender	  specific	  (Beres,	  2010;	  Jackson,	  1984;	  Miller,	  Exner,	  Williams,	  &	  Ehrhardt,	  2000).	  Despite	  this	  shift,	  there	  is	  a	  general	  lack	  of	  consideration	  given	  to	  the	  context	  in	  which	  sexual	  activity	  occurs	  and	  how	  gender	  dynamics	  impact	  and	  shape	  not	  only	  sexual	  risk	  but	  women’s	  expression	  of	  sexual	  pleasure,	  particularly	  within	  heterosexual	  relationships.	  Given	  these	  factors,	  coupled	  with	  the	  prominent	  use	  of	  CMC	  in	  day-­‐to-­‐day	  life,	  more	  attention	  needs	  to	  be	  paid	  to	  how	  these	  aspects	  shape	  women's	  sexual	  experiences.	  Further	  research	  is	  warranted	  to	  better	  our	  understanding	  of	  these	  issues	  with	  a	  view	  to	  enhancing	  education,	  prevention,	  and	  intervention	  strategies	  that	  improve	  women's	  sexual	  well-­‐being	  by	  reducing	  their	  sexual	  risk	  and	  improving	  their	  expression	  of	  sexual	  pleasure.	  	   This	  first	  chapter	  of	  the	  dissertation	  begins	  with	  a	  review	  of	  the	  relevant	  literature	  and	  provides	  a	  statement	  of	  the	  problem	  that	  is	  the	  focus	  of	  the	  research.	  Next,	  Chapter	  2	  provides	  the	  theoretical	  and	  methodological	  approach	  to	  the	  research,	  data	  collection,	  and	  how	  the	  key	  study	  variables	  were	  4	  	  conceptualized	  and	  operationalized.	  The	  key	  study	  findings	  are	  presented	  in	  Chapters	  3,	  4,	  and	  5.	  Finally,	  the	  dissertation	  closes	  with	  a	  general	  conclusion	  that	  ties	  these	  chapters	  and	  the	  research	  findings	  together.	  Each	  of	  the	  findings	  chapters	  introduces	  the	  research	  and	  provides	  a	  brief	  overview	  of	  the	  literature	  relevant	  to	  the	  topic	  of	  the	  chapter,	  the	  methods	  used	  for	  analysis,	  the	  results,	  and	  a	  conclusion.	  Because	  the	  structure	  of	  this	  dissertation	  is	  “manuscript	  based,”	  the	  findings	  chapters	  have	  some	  overlap	  in	  content,	  particularly	  pertaining	  to	  the	  sample,	  data	  collection,	  and	  the	  discussion	  of	  some	  key	  variables.	  	  Review	  of	  the	  Literature	  	  The	  majority	  of	  the	  literature	  reviewed	  for	  this	  research	  was	  drawn	  from	  a	  comprehensive	  search	  of	  the	  published	  literature	  in	  nursing,	  psychology,	  medicine,	  sociology,	  education,	  women’s	  studies,	  and	  communications	  and	  indexed	  in	  the	  following	  databases:	  Academic	  Search	  Complete,	  Medline,	  PubMed,	  CINAHL,	  PsycINFO,	  SocINDEX,	  ProQuest,	  ERIC,	  Communication	  and	  Mass	  Media	  Complete,	  and	  Women’s	  Studies	  International.	  Additional	  search	  strategies	  included	  manual	  searches	  for	  relevant	  literature	  cited	  in	  textbooks	  and	  retrieved	  journal	  articles.	  The	  searches	  were	  limited	  to	  English	  language	  manuscripts	  published	  within	  the	  last	  two	  decades,	  although	  relevant	  key	  literature	  published	  before	  this	  period	  was	  also	  included.	  For	  the	  literature	  search,	  the	  following	  key	  words	  and	  key	  word	  combinations	  were	  used:	  computer-­‐mediated	  communication,	  internet	  dating,	  online	  dating,	  women,	  sexually	  transmitted	  infections,	  sexually	  transmitted	  diseases,	  intimacy,	  trust,	  relationships,	  self-­‐disclosure,	  sexual	  communication,	  gender,	  gender	  roles,	  sexual	  scripts,	  orgasm,	  sexual	  safety,	  sexual	  risk,	  and	  interpersonal	  relationships.	  	   In	  what	  follows	  an	  overview	  is	  provided	  of	  the	  literature	  related	  to	  the	  current	  context	  of	  heterosexual	  dating,	  and	  the	  rising	  rates	  of	  HIV	  in	  adult	  women.	  Next,	  is	  a	  discussion	  that	  examines	  possible	  reasons	  for	  the	  increase	  in	  HIV	  in	  this	  population	  with	  a	  focus	  on	  the	  influence	  	  of	  CMC	  and	  a	  discussion	  of	  how	  traditional,	  gendered	  “sexual	  scripts,”	  a	  metaphor	  that	  attempts	  to	  explain	  sexual	  5	  	  encounters	  as	  social	  interactions	  (Gagnon	  &	  Simon,	  1973),	  influence	  women’s	  conformity	  to	  those	  scripts,	  and	  the	  types	  of	  sexual	  activities	  they	  engage	  in.	  	  The	  context	  of	  dating	  in	  the	  digital	  era	  	   The	  desire	  to	  find	  “that	  unique”	  individual	  and	  to	  establish	  a	  romantic	  relationship	  is	  the	  primary	  reason	  why	  most	  people	  in	  North	  America	  date	  (Smith	  &	  Duggan,	  2013).	  The	  tradition	  of	  initiating	  a	  romantic	  relationship	  spans	  many	  millennia,	  and,	  as	  those	  in	  the	  “dating	  pool”	  can	  attest,	  the	  search	  for	  “that	  special	  individual”	  can	  be	  challenging.	  People	  have	  sought	  assistance	  in	  meeting	  potential	  romantic	  partners	  through	  various	  means,	  some	  of	  which	  have	  included	  relying	  on	  one’s	  social	  network	  to	  match	  make,	  placing	  personal	  advertisements	  in	  newspapers,	  writing	  letters	  to	  persons	  of	  interest,	  and	  entering	  into	  prearranged	  marriages.	  Finding	  a	  romantic	  partner	  presents	  challenges,	  but	  new	  resources	  for	  communicating	  in	  the	  digital	  era	  have	  altered	  the	  context	  of	  dating	  —	  new	  avenues	  for	  meeting	  potential	  love	  interests	  are	  available.	  Much	  of	  this	  change	  can	  be	  attributed	  to	  the	  advent	  and	  ubiquitous	  availability	  of	  the	  internet,	  which	  has	  revolutionized	  how	  people	  meet	  and	  interact	  with	  each	  other.	  Traditionally,	  most	  dating	  occurred	  within	  a	  FTF	  setting	  with	  potential	  romantic	  partners	  limited	  to	  one’s	  social	  network.	  Dating	  in	  the	  digital	  era,	  however,	  not	  only	  affords	  people	  a	  much	  faster	  and	  efficient	  way	  	  of	  meeting	  dating	  partners,	  it	  also	  provides	  a	  larger	  network	  of	  individuals	  from	  which	  to	  choose,	  people	  that	  previously	  would	  have	  been	  unknown	  or	  inaccessible.	  Over	  the	  last	  decade,	  digital	  dating	  has	  become	  increasingly	  popular	  among	  adults	  (Cohn,	  Passel,	  Wang,	  &	  Livingston,	  2011).	  Social	  forces	  driving	  the	  growth	  in	  dating	  assisted	  by	  new	  internet	  technologies,	  what	  is	  commonly	  referred	  to	  as	  CMC,	  include:	  1)	  greater	  career,	  family,	  and	  time	  pressures,	  2)	  a	  larger	  proportion	  of	  single	  people	  in	  the	  population	  (due	  to	  rising	  divorce	  rates),	  and	  3)	  a	  decline	  in	  workplace	  romances	  (due	  to	  growing	  sensitivities	  to	  sexual	  harassment)	  (Brym	  &	  Lenton,	  2001;	  Valkenburg	  &	  Peter,	  2007).	  	  	   Given	  the	  changing	  context	  of	  dating,	  infectious	  disease	  specialists	  have	  been	  concerned	  that	  the	  use	  of	  CMC	  for	  dating	  purposes	  may	  potentiate	  the	  spread	  of	  STIs	  and	  HIV	  (Bateson,	  Weisberg,	  6	  	  McCaffery,	  &	  Luscombe,	  2012;	  McFarlane,	  Bull,	  &	  Reitmeijer,	  2000;	  Rietmeijer	  &	  McFarlane,	  2009).	  It	  is	  hypothesized	  that	  faster	  and	  easier	  access	  to	  a	  wider	  pool	  of	  sexual	  partners	  may	  translate	  into	  more	  sexual	  partners,	  more	  frequent	  engagement	  in	  high-­‐risk	  sexual	  behaviour,5	  and	  exposure	  to	  new	  sexual	  networks	  (McFarlane	  et	  al.,	  2000;	  Rietmeijer	  &	  McFarlane,	  2009).	  Associations	  between	  CMC,	  high-­‐risk	  sexual	  behaviour,	  and	  disease	  acquisition	  has	  been	  found	  in	  several	  studies	  of	  men	  who	  have	  sex	  with	  men	  (MSM)	  (Elford	  et	  al.,	  2001;	  Horvath	  et	  al.,	  2008;	  Kim	  et	  al.,	  2001).	  Studies	  focused	  on	  the	  heterosexual	  population,	  however,	  have	  produced	  inconsistent	  results.	  For	  example,	  some	  researchers	  have	  reported	  that	  the	  use	  of	  CMC	  is	  associated	  with	  a	  higher	  number	  of	  partners,	  greater	  engagement	  in	  high-­‐risk	  sexual	  behaviour,	  and	  more	  STIs	  in	  comparison	  with	  dating	  achieved	  through	  traditional	  FTF	  methods	  (McFarlane,	  2002;	  McFarlane	  et	  al.,	  2000;	  Rietmeijer	  &	  McFarlane,	  2009).	  Other	  researchers	  have	  failed	  to	  find	  a	  relationship	  between	  CMC	  or	  FTF	  interaction	  and	  the	  risk	  of	  infection	  or	  high-­‐risk	  behaviour	  (Al-­‐Tayyib,	  McFarlane,	  Kachur,	  &	  Rietmeijer,	  2008;	  Bolding,	  Davis,	  Hart,	  Sherr,	  &	  Elford,	  2006;	  Daneback,	  Mansson,	  &	  Ross,	  2007;	  Mustanski,	  2007).	   Another	  factor	  that	  influences	  sexual	  risk	  is	  the	  lack	  of	  specific	  communication	  between	  partners	  about	  their	  sexual	  histories	  and	  the	  sexual	  activities	  most	  risky	  for	  HIV	  transmission	  (Buysse	  &	  Ickes,	  1999;	  Niccolai	  et	  al.,	  2005;	  Quina,	  Harlow,	  Morokoff,	  Burkholder,	  &	  Deiter,	  2000).	  In	  comparison	  with	  FTF	  interactions,	  CMC	  is	  thought	  to	  elicit	  more	  open	  and	  honest	  communication	  (Schouten,	  Valkenburg,	  &	  Peter,	  2007;	  Tidwell	  &	  Walther,	  2002).	  The	  anonymity	  of	  CMC	  purportedly	  allows	  individuals	  to	  be	  more	  forthcoming	  in	  disclosing	  sensitive	  information	  and	  to	  feel	  less	  constrained	  in	  discussing	  specific	  topics,	  ideas,	  emotions,	  and	  behaviour,	  thus	  leading	  to	  the	  sharing	  of	  more	  intimate	  confidences	  earlier	  than	  would	  occur	  within	  FTF	  interactions	  (McKenna	  &	  Bargh,	  2000;	  Schouten	  et	  al.,	  2007;	  Tidwell	  &	  Walther,	  2002).	  In	  relation	  to	  sexual	  risk,	  however,	  there	  is	  little	  evidence	  to	  indicate	  that	  people,	  especially	  women,	  using	  CMC	  are	  communicating	  or	  negotiating	  about	  this	  topic	  (Couch	  &	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  5	  High-­‐risk	  sexual	  behaviour	  is	  behaviour	  that	  has	  a	  high	  likelihood	  of	  transmitting	  HIV.	  	  7	  	  Liamputtong,	  2007;	  McFarlane	  et	  al.,	  2000;	  Padgett,	  2007).	  Research	  indicates	  that,	  no	  matter	  what	  form	  of	  communication	  people	  use,	  in	  general,	  discussions	  about	  sexual	  risk	  or	  low-­‐risk	  sexual	  activity	  occur	  infrequently,	  and	  these	  matters,	  when	  discussed,	  are	  usually	  alluded	  to	  through	  vague	  references	  (e.g.,	  references	  to	  wanting	  an	  infection-­‐free	  partner)	  (Kim,	  Kent,	  McFarland,	  &	  Klausner,	  2001).	  Often,	  knowledge	  about	  a	  partner's	  sexual	  history	  or	  HIV	  status	  is	  gathered	  indirectly	  through	  ambiguous	  communication	  because	  very	  few	  people	  ask	  their	  partners	  direct	  questions	  (Crosby,	  Yarber,	  &	  Meyerson,	  2000;	  Williams,	  Kimble,	  Covell,	  &	  Weiss,	  1992).	  Yet	  communication	  is	  vital.	  A	  meta-­‐analysis	  of	  communication	  about	  safer	  sex	  practices	  and	  condom	  use	  found	  that	  direct	  communication	  about	  condom	  use	  is	  one	  of	  the	  strongest	  predictors	  of	  actual	  condom	  use	  (Noar,	  Carlyle,	  &	  Cole,	  2006).	  Computer-­‐mediated	  versus	  face-­‐to-­‐face	  communication	  	   Given	  that	  CMC	  potentially	  facilitates	  sexual	  encounters	  because	  of	  its	  accessibility	  and	  speed	  at	  which	  people	  can	  communicate	  when	  developing	  a	  relationship,	  examining	  CMC	  theory	  and	  its	  differences	  from	  FTF	  communication	  may	  provide	  insight	  into	  factors	  that	  influence	  how	  relationships	  develop	  in	  CMC,	  and	  how	  this	  may	  affect	  sexual	  interactions	  and	  ultimately	  sexual	  risk.	  In	  recent	  years,	  much	  emphasis	  has	  been	  placed	  on	  the	  psychological	  and	  behavioural	  differences	  between	  CMC	  and	  FTF	  communication.	  Early	  theorists	  claimed	  that	  because	  CMC	  filters	  out	  important	  visual,	  auditory,	  and	  social/contextual	  cues,	  communication	  (compared	  with	  FTF)	  becomes	  impersonal	  and	  provides	  an	  environment	  for	  uninhibited	  aggressiveness.	  The	  impersonal	  nature	  of	  CMC	  was	  also	  thought	  to	  create	  feelings	  of	  isolation	  and	  loneliness	  among	  users;	  therefore,	  it	  was	  considered	  an	  inappropriate	  means	  of	  developing	  interpersonal	  relationships	  (Walther,	  1993).	  An	  interesting	  aspect	  of	  CMC	  is	  how	  it	  challenges	  traditional	  theories	  of	  communication	  and	  relationship	  development.	  More	  recently,	  a	  growing	  body	  of	  research	  has	  focussed	  on	  the	  benefits	  of	  CMC	  in	  developing	  interpersonal	  relationships	  (Tidwell	  &	  Walther,	  2002;	  Walther,	  1996).	  Unlike	  FTF	  encounters,	  in	  which	  the	  social	  meaning	  of	  an	  interaction	  is	  conveyed	  through	  verbal,	  nonverbal,	  and	  contextual	  cues,	  CMC	  primarily	  relies	  on	  written	  8	  	  text,	  which	  lacks	  social	  cues,	  such	  as	  facial	  expressions,	  body	  language	  and	  posture,	  and	  gestures.	  The	  focus	  of	  much	  of	  the	  research	  on	  CMC,	  therefore,	  has	  been	  on	  how	  the	  linguistic	  characteristics	  of	  text-­‐based	  electronic	  messages,	  and	  the	  absence	  of	  nonverbal	  and	  contextual	  cues,	  impact	  social	  connections	  and	  the	  development	  of	  interpersonal	  relationships.	  	  Social	  Presence	  Theory	  (SPT)	  (Short,	  Williams,	  &	  Christie,	  1976),	  and	  other	  similar	  early	  theories	  of	  CMC,	  collectively	  known	  as	  “cues	  filtered	  out”	  theory	  (Culnan	  &	  Markus,	  1987),	  contends	  that	  as	  the	  availability	  and	  number	  of	  visual	  (physical	  appearance,	  facial	  expressions,	  posture,	  dress),	  auditory	  (voice	  inflection	  and	  quality),	  and	  other	  contextual	  cues	  increase	  within	  a	  medium,	  so	  does	  the	  attention	  that	  is	  paid	  by	  the	  communicator	  to	  the	  presence	  of	  others	  participating	  in	  the	  interaction.	  Hence,	  social	  presence	  is	  the	  extent	  to	  which	  one	  believes	  that	  one’s	  partner	  is	  “present”	  and	  engaged	  in	  the	  social	  interaction	  (Ramirez	  &	  Zhang,	  2007;	  Whitty	  &	  Gavin,	  2001).	  The	  degree	  of	  social	  presence	  is	  dependent	  on	  the	  number	  of	  cues	  available	  within	  any	  given	  medium.	  Higher	  levels	  of	  social	  presence	  are	  a	  result	  of	  more	  available	  cues,	  whereas	  lower	  levels	  result	  from	  fewer	  cues.	  A	  decrease	  in	  social	  presence	  is	  predicted	  to	  reduce	  one’s	  awareness	  of	  one's	  partner.	  This	  lack	  of	  awareness	  is	  thought	  to	  hinder	  communication	  and	  produce	  interactions	  that	  are	  less	  socially	  oriented.	  These	  early	  CMC	  theories	  contended	  that	  visual	  (physical	  appearance,	  facial	  expressions,	  posture,	  dress),	  auditory	  (voice	  inflection	  and	  quality),	  and	  other	  contextual	  cues	  are	  necessary	  in	  the	  development	  of	  meaningful	  interpersonal	  relationships	  and	  social	  connections	  (Culnan	  &	  Markus,	  1987).	  Because	  these	  social	  cues	  are	  absent	  in	  CMC,	  social	  presence	  is	  predicted	  to	  be	  low,	  thus	  resulting	  in	  online	  relationships	  that	  are	  more	  impersonal,	  cold,	  and	  task-­‐focused	  than	  are	  FTF	  relationships.	  Proponents	  of	  the	  “cues	  filtered	  out”	  theory	  maintained	  that	  CMC	  is	  not	  conducive	  to	  developing	  meaningful	  relationships	  (Walther,	  1996).	  While	  some	  early	  CMC	  research	  (Rice,	  1993;	  Rice	  &	  Love,	  1987;	  Siegel,	  Dubrovsky,	  Kiesler,	  &	  McGuire,	  1986;	  Sproull	  &	  Kiesler,	  1986)	  supported	  the	  cues	  filtered	  out	  theory,	  much	  of	  this	  research	  had	  been	  conducted	  within	  business	  and	  government	  institutions,	  and	  was	  focused	  on	  impersonal,	  task-­‐oriented	  9	  	  activities	  (e.g.,	  completing	  a	  collaborative	  project	  or	  forming	  work	  relationships)	  that	  involved	  one-­‐time-­‐only	  or	  time-­‐limited	  interactions	  (Walther,	  1996).	  	  Over	  the	  last	  decade,	  the	  use	  of	  the	  internet	  for	  social	  interaction	  has	  increased	  markedly,	  and	  new	  theories	  have	  emerged	  that	  counter	  the	  early	  CMC	  relationship	  theories.	  The	  Social	  Information	  Processing	  (SIP)	  perspective	  rejects	  the	  view	  that	  people	  using	  CMC	  are	  incapable	  of	  forming	  personal,	  intimate	  relationships.	  Instead,	  according	  to	  SIP,	  CMC	  users	  are	  inherently	  motivated	  to	  develop	  social	  relationships,	  and	  will	  compensate	  for	  missing	  social	  information	  by	  adapting	  to	  whatever	  social	  cues	  are	  available	  in	  the	  medium	  they	  are	  using	  (Walther,	  Loh,	  &	  Granka,	  2005).	  For	  example,	  in	  CMC,	  a	  reduction	  in	  nonverbal	  and	  contextual	  cues	  forces	  the	  users	  to	  use	  verbal	  and	  linguistic	  cues	  (e.g.,	  word	  style,	  word	  choice,	  content)	  to	  acquire	  and	  convey	  relational	  information	  (e.g.,	  characteristics,	  attitudes,	  and	  emotions	  of	  others)	  and	  to	  form	  impressions	  of	  each	  other	  (Tidwell	  &	  Walther,	  2002;	  Walther	  &	  Anderson,	  1992).	  	  SIP	  theory	  maintains	  that,	  in	  relational	  development,	  a	  major	  difference	  between	  CMC	  and	  FTF	  communication	  is	  the	  element	  of	  time	  (Walther	  &	  Anderson,	  1992).	  In	  CMC,	  relationship	  development	  occurs	  over	  a	  longer	  period	  of	  time	  compared	  with	  FTF	  interaction	  because	  users	  must	  adapt	  to	  the	  reduced	  cues	  and	  adjust	  their	  messages	  to	  seek	  sufficient	  information	  for	  impression	  formation.	  Once	  CMC	  users	  have	  formed	  an	  impression	  of	  a	  previously	  unknown	  partner,	  over	  time,	  they	  begin	  to	  test	  their	  assumptions	  about	  the	  partner	  by	  engaging	  in	  knowledge-­‐generating	  and	  uncertainty-­‐reduction	  communication	  strategies	  (Walther	  et	  al.,	  2005).	  Because	  social	  information	  is	  exchanged	  in	  CMC	  through	  one	  channel	  of	  communication	  (written	  text),	  the	  accrual	  of	  information	  is	  assumed	  to	  be	  much	  slower	  than	  with	  FTF	  interactions	  where	  information	  flows	  through	  many	  channels.	  According	  to	  Walther	  (1996),	  how	  quickly	  CMC	  relationships	  develop	  depends	  more	  on	  the	  rate	  at	  which	  information	  is	  exchanged	  between	  partners,	  rather	  than	  on	  the	  amount	  of	  information	  that	  is	  exchanged.	  In	  other	  10	  	  words,	  as	  CMC	  users	  exchange	  information	  over	  a	  period	  of	  time,	  their	  relationship	  will	  develop	  in	  much	  the	  same	  way	  as	  those	  interacting	  FTF.	  	  According	  to	  SIP	  theory,	  CMC	  users	  employ	  different	  information-­‐seeking	  strategies,	  depending	  on	  their	  relational	  goals	  and	  whether	  future	  interaction	  is	  anticipated.	  CMC	  users	  who	  anticipate	  future	  interaction,	  and	  who	  intend	  to	  engage	  in	  long-­‐term	  communication	  with	  their	  partners,	  have	  been	  found	  to	  seek	  and	  exchange	  more	  personal	  information,	  to	  evaluate	  their	  partners	  in	  a	  more	  positive	  light,	  and	  to	  disclose	  more	  information	  about	  themselves	  than	  those	  engaged	  in	  short-­‐term	  interactions	  or	  who	  communicate	  in	  offline	  settings	  (Tidwell	  &	  Walther,	  2002;	  Utz,	  2000;	  Walther,	  1994;	  Walther,	  Slovacek,	  &	  Tidwell,	  2001).	  SIP	  theory	  implies	  that	  CMC	  is	  able	  to	  facilitate	  meaningful,	  personal	  relationships	  similar	  to	  those	  developed	  through	  FTF	  interactions	  when	  sufficient	  time	  exists.	  	  Walther	  (1996;	  2007)	  and	  colleagues	  (Walther	  et	  al.,	  2001)	  proposed	  a	  theory	  of	  hyperpersonal	  communication	  that	  expands	  SIP	  theory.	  In	  addition	  to	  CMC	  facilitating	  the	  development	  of	  personal	  relationships,	  hyperpersonal	  theory	  contends	  that	  CMC	  may,	  in	  fact,	  enhance	  relational	  outcomes.	  According	  to	  this	  theory,	  CMC	  users	  can	  develop	  close	  and	  intimate	  relationships	  more	  quickly	  than	  they	  can	  in	  FTF	  settings	  because	  the	  medium	  presents	  users	  with	  several	  technological	  advances	  that	  provide	  a	  unique	  environment	  for	  interacting.	  For	  example,	  CMC	  users	  communicate	  with	  relative	  anonymity,	  which	  allows	  them	  to	  overcome	  some	  of	  the	  social	  awkwardness	  associated	  with	  FTF	  interactions.	  Social	  awkwardness	  can	  also	  be	  overcome	  because	  CMC	  users	  can	  be	  selective	  in	  the	  information	  they	  present	  about	  themselves	  to	  others.	  Walther	  (1996;	  2007)	  alleged	  that	  the	  ability	  of	  CMC	  users	  to	  control,	  and	  thus	  be	  strategic	  in	  their	  self-­‐presentation,	  ultimately	  contributes	  to	  the	  acceleration	  of	  intimacy.	  Given	  that	  a	  sense	  of	  trust	  and	  intimacy	  within	  a	  relationship	  can	  increase	  sexual	  risk	  among	  women	  (Gebhardt,	  Kuyper,	  &	  Greunsven,	  2003),	  CMC	  may	  lead	  to	  increased	  sexual	  risk	  because	  over	  time	  partners	  are	  trusted	  and	  believed	  to	  be	  low	  risk.	  	  11	  	  Unlike	  FTF	  interaction,	  CMC	  is	  often	  asynchronous,	  meaning	  that	  there	  is	  a	  delay	  in	  message	  transmission	  and	  response.	  Composing	  a	  message	  is	  usually	  a	  solitary	  process	  that	  occurs	  in	  physical	  isolation	  without	  interruption	  or	  immediate	  censorship	  from	  others.	  CMC	  users	  have	  time	  to	  carefully	  reflect	  on	  what	  they	  want	  to	  communicate,	  and	  can	  spend	  time	  consciously	  constructing	  and	  refining	  their	  communication	  and	  thinking	  about	  how	  best	  to	  present	  themselves	  to	  others.	  According	  to	  hyperpersonal	  theory,	  relationships	  may	  develop	  faster	  than	  those	  developed	  through	  FTF	  interaction	  partly	  because	  of	  the	  greater	  cognitive	  effort	  CMC	  users	  expend	  in	  constructing	  and	  refining	  their	  communication.	  	  Walther	  (1996;	  2007)	  and	  colleagues	  	  (Walther	  &	  Anderson,	  1992)	  further	  postulated	  that	  because	  CMC	  users	  on	  the	  receiving	  end	  of	  a	  communication	  lack	  social	  cues,	  they	  are	  likely	  to	  form	  idealized	  perceptions	  of	  their	  partners	  because	  they	  over-­‐interpret	  the	  limited	  information	  that	  has	  been	  sent.	  When	  information	  about	  a	  partner	  is	  interpreted	  as	  positive,	  receivers	  are	  likely	  to	  form	  an	  idealistic	  impression	  of	  that	  partner.	  In	  summary,	  Walther	  (1996)	  argued	  that	  the	  combination	  of	  elements	  in	  the	  CMC	  process	  (sender,	  receiver,	  channel,	  and	  feedback	  process)	  tend	  to	  heighten	  positive	  impressions	  and	  enhance	  interpersonal	  relations	  because	  people	  have:	  (a)	  more	  control	  over	  their	  interaction,	  (b)	  a	  greater	  opportunity	  to	  plan	  how	  they	  present	  themselves,	  (c)	  more	  time	  to	  reflect	  on	  and	  address	  the	  goals	  present	  in	  others'	  messages,	  and	  (d)	  their	  behaviour	  confirmed	  through	  positive	  feedback	  loops.	  Through	  these	  processes,	  hyperpersonal	  communication	  theory	  proposes	  that	  CMC	  may	  facilitate	  higher	  levels	  of	  self-­‐disclosure,	  trust,	  and	  relational	  intimacy	  than	  that	  found	  in	  comparable	  FTF	  interactions	  (Hian,	  Chuan,	  Trevor,	  &	  Detenber,	  2004;	  Tidwell	  &	  Walther,	  2002;	  Walther,	  1996;	  Walther	  et	  al.,	  2001).	  	  	  	  To	  date,	  the	  majority	  of	  research	  examining	  CMC	  has	  focussed	  on	  perceived	  similarities	  and	  differences	  in	  communication	  and	  the	  initiation	  and	  development	  of	  relationships	  compared	  with	  those	  initiated	  in	  FTF	  settings.	  Limited	  attention	  has	  been	  paid	  to	  the	  impact	  of	  these	  differences	  on	  12	  	  relationship	  development	  and	  how	  this	  may	  affect	  sexual	  interactions	  and	  sexual	  risk.	  Although	  several	  studies	  have	  established	  an	  association	  between	  the	  use	  of	  CMC	  to	  seek	  sex	  (as	  opposed	  to	  romance)	  and	  high-­‐risk	  sexual	  behaviour,	  few	  have	  examined	  the	  sexual	  well-­‐being	  of	  individuals	  who	  use	  CMC	  for	  the	  primary	  purpose	  of	  finding	  or	  maintaining	  a	  romantic	  relationship	  leading	  to	  sexual	  activity.	  The	  rapidly	  increasing	  use	  of	  the	  internet	  to	  find	  and	  maintain	  relationships	  with	  romantic	  partners,	  and	  the	  lack	  of	  studies	  conducted,	  warrant	  research	  to	  develop	  an	  understanding	  of	  the	  factors	  that	  influence	  sexual	  decision	  making	  and	  sexual	  risk,	  especially	  those	  of	  women. The	  factors	  that	  are	  known	  to	  influence	  HIV	  rates	  are	  described	  in	  the	  following	  section.	  HIV	  rates	  in	  adult	  women	  The	  reported	  rates	  of	  HIV	  have	  increased	  significantly	  among	  heterosexual	  adults	  (25	  years	  of	  age	  and	  older)	  in	  the	  last	  decade	  (Canadian	  Public	  Health	  Association,	  2005;	  Centers	  for	  Disease	  Control	  and	  Prevention,	  2010a,	  2010b).6	  Yet	  to	  date,	  few	  studies	  have	  been	  conducted	  to	  examine	  the	  reasons	  for	  these	  increased	  rates	  among	  adults. Worldwide,	  the	  proportion	  of	  women	  infected	  with	  HIV	  has	  been	  steadily	  increasing,	  and	  has	  surpassed	  that	  of	  men	  in	  the	  last	  decade	  (World	  Health	  Organization,	  2010).	  Heterosexual	  contact	  is	  considered	  the	  main	  risk	  factor	  for	  HIV	  infection	  in	  women	  	  and	  represents	  the	  second	  highest	  exposure	  category	  in	  North	  America;	  men	  who	  have	  sex	  with	  men	  (MSM)	  being	  the	  highest	  exposure	  category	  (Centers	  for	  Disease	  Control	  and	  Prevention,	  2010a,	  2010b;	  Public	  Health	  Agency	  of	  Canada,	  2013).	  Over	  the	  last	  several	  years,	  the	  proportion	  of	  women	  acquiring	  HIV	  through	  heterosexual	  contact	  has	  been	  significantly	  larger	  than	  that	  of	  men.	  For	  example,	  in	  2010,	  84%	  of	  new	  HIV	  infections	  in	  women	  in	  the	  United	  States	  were	  attributed	  to	  heterosexual	  contact	  (Centers	  for	  Disease	  Control	  and	  Prevention,	  2014).	  A	  similar	  trend	  has	  been	  observed	  in	  Canada	  with	  73%	  of	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  6	  For	  the	  purpose	  of	  this	  dissertation,	  the	  term	  adult	  refers	  to	  heterosexual	  men	  or	  women	  25	  years	  of	  age	  or	  older.	  This	  includes	  middle-­‐aged	  and	  older	  adults.	  13	  	  new	  HIV	  infections	  being	  in	  adult	  women,	  versus	  21%	  being	  in	  adult	  men,	  and	  they	  are	  attributed	  to	  heterosexual	  contact	  (Public	  Health	  Agency	  of	  Canada,	  2013).	  	  	  Women	  in	  North	  America,	  among	  other	  population	  groups	  (e.g.,	  MSM,	  injection	  drug	  users,	  Aboriginal	  people,	  and	  youth),	  are	  disproportionately	  affected	  by	  HIV	  (Exner,	  Hoffman,	  Dworkin,	  &	  Ehrhardt,	  2003;	  Fasula,	  Carry,	  &	  Miller,	  2014).	  Black/African	  American	  and	  Hispanic/Latino	  women	  are	  particularly	  affected	  compared	  with	  women	  of	  other	  races/ethnicities	  (Centers	  for	  Disease	  Control	  and	  Prevention,	  2014).	  In	  the	  US,	  of	  the	  total	  number	  of	  estimated	  new	  HIV	  infections	  among	  women	  in	  2010,	  64%	  were	  in	  African	  Americans,	  18%	  were	  in	  whites,	  and	  15%	  were	  in	  Hispanic/Latino	  women	  (Centers	  for	  Disease	  Control	  and	  Prevention,	  2014).	  Various	  factors	  have	  contributed	  to	  the	  rise	  in	  HIV	  in	  women.	  The	  social	  determinants	  of	  health,	  including	  poverty,	  homelessness,	  lack	  of	  social	  support,	  lack	  of	  education,	  and	  abuse—both	  physical	  and	  sexual—continue	  to	  drive	  the	  HIV	  epidemic	  (Dworkin	  et	  al.,	  2007;	  Exner	  et	  al.,	  2003).	  These	  factors	  impede	  women's	  autonomous	  decision	  making	  and	  restrict	  their	  ability	  to	  make	  healthful	  choices	  and	  maintain	  their	  health	  (Gupta,	  2001;	  Smith	  &	  Duggan,	  2013).	  Although	  we	  acknowledge	  the	  importance	  of	  and	  diverse	  array	  of	  determinants,	  a	  full	  consideration	  of	  these	  social	  determinants	  are	  beyond	  the	  scope	  of	  this	  research.	  	  Although	  the	  social	  determinants	  of	  health	  provide	  some	  explanation	  for	  the	  rise	  in	  adult	  women’s	  HIV	  rates,	  another	  factor	  is	  related	  to	  a	  lack	  of	  awareness	  and	  education	  (Idso,	  2009;	  Johnson,	  2013).	  Adult	  women	  have	  not	  been	  targets	  of	  HIV	  education	  or	  prevention	  campaigns	  and	  they	  have	  been	  largely	  overlooked	  by	  HIV	  researchers.	  It	  is	  assumed	  that	  the	  majority	  of	  adult	  women	  are	  married	  or	  in	  long-­‐term	  relationships	  and,	  therefore,	  not	  at	  risk	  for	  infection	  (Sherman,	  Harvey,	  &	  Noell,	  2005).	  However,	  there	  are	  many	  adult	  women	  today	  who	  are	  single	  (due	  to	  divorce,	  later	  marriage,	  or	  death	  of	  a	  spouse)	  and	  dating,	  and	  therefore	  are	  initiating	  new	  sexual	  relationships.	  Those	  who	  have	  left	  long-­‐term	  relationships,	  and	  are	  subsequently	  new	  to	  dating,	  may	  not	  be	  aware	  of	  the	  HIV	  risks.	  Many	  of	  these	  women	  have	  not	  had	  to	  think	  about	  HIV	  let	  alone	  risk	  prevention.	  Others	  may	  not	  consider	  14	  	  themselves	  to	  be	  at	  risk	  for	  HIV	  transmission	  because	  they	  incorrectly	  assume	  that	  these	  infections	  do	  not	  exist	  in	  their	  age	  group	  or	  social	  networks	  (Rich,	  2001;	  Savasta,	  2004).	  Paranjape	  et	  al.	  (2006)	  found	  that	  separated,	  divorced,	  and	  widowed	  women	  had	  the	  highest	  frequency	  of	  non-­‐condom	  use.	  Of	  the	  sexually	  active	  women	  in	  their	  study,	  only	  13%	  reported	  that	  they	  used	  condoms	  consistently.	  Similar	  findings	  have	  been	  reported	  by	  others.	  For	  instance,	  Deering,	  Tyndall,	  and	  Koehoorn	  (2010)	  found	  that	  adult	  women	  were	  significantly	  less	  likely	  to	  have	  used	  a	  condom	  during	  their	  last	  sexual	  intercourse	  compared	  with	  younger	  women	  (i.e.,	  15	  to	  24	  year	  olds)	  and	  adult	  men.	  	  Several	  barrier	  methods	  exist	  to	  prevent	  HIV	  transmission,	  however,	  when	  used	  correctly,	  the	  male	  condom	  is	  considered	  to	  be	  the	  most	  effective	  (World	  Health	  Organization,	  2007).	  It	  is	  also	  the	  most	  widely	  promoted	  and	  thus	  the	  most	  familiar	  method.7	  Condom	  use	  for	  many	  heterosexual	  adults,	  however,	  has	  been	  associated	  with	  the	  prevention	  of	  pregnancy,	  rather	  than	  with	  its	  effectiveness	  as	  a	  barrier	  in	  the	  prevention	  of	  STIs	  or	  HIV	  (Pratt,	  Gascoyne,	  Cunningham,	  &	  Tunbridge,	  2010).	  A	  lack	  of	  awareness	  and	  information	  related	  to	  how	  to	  prevent	  HIV	  may	  be	  a	  contributing	  factor	  in	  the	  observed	  rates	  of	  infection	  in	  adult	  women.	  	  The	  change	  in	  dating	  culture	  due	  to	  online	  technologies	  combined	  with	  the	  general	  lack	  of	  HIV	  awareness	  become	  especially	  problematic	  when	  considering	  the	  implications	  for	  those	  entering	  the	  dating	  scene	  and	  starting	  new	  sexual	  relationships	  (Gott,	  2001;	  Lindau	  et	  al.,	  2007).	  Some	  literature	  suggests	  that	  adult	  women	  using	  CMC	  are	  more	  vulnerable	  to	  HIV	  because	  they	  are	  likely	  to	  engage	  in	  high-­‐risk	  sexual	  behaviour	  (Bateson	  et	  al.,	  2012;	  McFarlane,	  Kachur,	  Bull,	  &	  Rietmeijer,	  2004;	  Padgett,	  2007).	  The	  evidence	  suggests	  that	  sexual	  intimacy	  is	  accelerated	  for	  those	  using	  CMC	  to	  find	  romantic	  partners	  compared	  with	  those	  that	  rely	  on	  FTF	  interactions	  (Ross,	  2005).	  CMC	  allows	  for	  relationships	  to	  become	  intense	  and	  eroticized	  very	  quickly,	  even	  before	  a	  FTF	  meeting	  occurs	  (Cooper	  &	  Sportolari,	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  7	  We	  focus	  on	  evidence	  primarily	  related	  to	  male	  condoms	  for	  the	  reasons	  cited	  above,	  but	  acknowledge	  that	  there	  are	  many	  other	  sexual	  activities	  that	  pose	  low	  risk	  for	  STI/HIV	  transmission,	  such	  as	  sexual	  activities	  involving	  non-­‐penetrative	  sex.	  	  15	  	  1997).	  The	  erotic	  conversations	  that	  CMC	  allows	  may	  heighten	  sexual	  feelings	  and	  romantic	  fantasies	  to	  the	  point	  that	  any	  discussion	  about	  safer	  sex	  (e.g.,	  condom	  use,	  disclosure	  of	  sexual	  history,	  or	  being	  tested	  for	  HIV)	  runs	  the	  risk	  of	  destroying	  the	  romance	  or	  threatening	  the	  integrity	  of	  the	  relationship,	  especially	  if,	  for	  example,	  condom	  use	  must	  be	  negotiated.	  Having	  to	  consider	  HIV	  issues,	  while	  at	  the	  same	  time	  initiating	  new	  sexual	  relationships,	  may	  be	  especially	  challenging	  for	  many	  women.	  Given	  the	  rise	  in	  popularity	  of	  CMC, especially	  among	  those	  between	  30	  and	  60	  years	  of	  age	  (Brym	  &	  Lenton,	  2001;	  Cooper,	  Mansson,	  Daneback,	  Tikkanen,	  &	  Ross,	  2003;	  Rietmeijer,	  Bull,	  McFarlane,	  Patnaik,	  &	  Douglas,	  2003),	  it	  is	  concerning	  that	  so	  little	  research	  has	  been	  conducted	  on	  (a)	  how	  adult	  women	  make	  decisions	  about	  the	  types	  of	  sexual	  activities	  they	  engage	  in	  and	  (b)	  whether	  the	  type	  of	  communication	  method	  used	  influences	  their	  decisions.	  	  	   In	  addition	  to	  these	  sociocultural	  factors,	  women	  are	  more	  susceptible	  to	  HIV	  transmission	  relative	  to	  men	  because	  of	  their	  biology.	  It	  is	  generally	  accepted	  that	  HIV	  is	  much	  more	  easily	  transmitted	  from	  men	  to	  women	  than	  from	  women	  to	  men	  (Buve,	  Gourbin,	  &	  Laga,	  2008);	  women	  have	  	  larger	  mucosal	  surface	  areas	  (i.e.,	  vaginal	  and	  cervical)	  that	  can	  be	  exposed	  to	  HIV	  pathogens	  than	  do	  men	  (i.e.,	  urethral	  meatus).	  In	  addition,	  their	  surface	  areas,	  when	  exposed	  to	  the	  pathogens,	  are	  exposed	  for	  a	  more	  prolonged	  period	  of	  time.	  Both	  of	  these	  factors	  (larger	  surface	  area	  and	  longer	  exposure)	  increase	  the	  probability	  of	  infection	  (Buve	  et	  al.,	  2008).	  Older	  adult	  women	  (e.g.,	  post	  menopause)	  are	  at	  greater	  risk	  of	  HIV	  because	  of	  vaginal	  dryness	  and	  thinning	  of	  the	  vulvovaginal	  skin,	  which	  predispose	  them	  to	  tissue	  trauma	  during	  penetrative	  sex,	  allowing	  for	  easier	  transmission	  of	  viruses	  and	  bacteria	  (Buve	  et	  al.,	  2008).	  In	  addition,	  older	  adult	  men	  may	  not	  have	  used	  condoms	  or	  may	  be	  reluctant	  to	  use	  them	  for	  fear	  of	  erectile	  dysfunction	  (Potts,	  Grace,	  Gavey,	  &	  Vares,	  2004).	  This	  may	  pose	  yet	  another	  barrier	  for	  women	  wanting	  to	  negotiate	  protection	  from	  HIV.	  A	  further	  concern	  is	  co-­‐infection.	  Those	  who	  are	  unaware	  that	  they	  have	  an	  STI	  (i.e.,	  are	  undiagnosed)	  are	  at	  greater	  risk	  of	  acquiring	  HIV	  as	  well	  as	  other	  infectious	  and	  chronic	  diseases	  (Wong,	  Chan,	  Boi-­‐Doku,	  &	  McWatt,	  2012).	  	  16	  	  Sexual	  risk	  	   A	  core	  concept	  in	  this	  study	  is	  that	  of	  sexual	  risk.	  While	  many	  factors	  (e.g.,	  sexual	  violence,	  sexual	  coercion,	  sexual	  abuse)	  place	  women	  at	  sexual	  risk	  that	  could	  lead	  to	  poor	  physical	  and	  emotional	  outcomes	  (Akiko,	  Christensen,	  Tabler,	  Ashby,	  &	  Olson,	  2014;	  Bonomi,	  Anderson,	  Rivara,	  &	  Thompson,	  2007),	  we	  refer	  to	  sexual	  risk	  as	  those	  sexual	  acts	  that	  have	  the	  riskiest	  or	  greatest	  likelihood	  of	  transmitting	  HIV	  pathogens.	  Much	  of	  the	  research	  related	  to	  sexual	  risk	  and	  women	  has	  been	  related	  to	  STIs	  and	  not	  necessarily	  HIV.	  Thus,	  this	  research	  intends	  to	  address	  the	  gap	  related	  to	  risk	  of	  HIV	  transmission	  as	  it	  pertains	  to	  sexual	  and	  dating	  relationships.	  A	  commonly	  accepted	  method	  for	  assessing	  an	  individual’s	  risk	  for	  HIV	  is	  to	  base	  it	  on	  behaviour	  that	  is	  most	  likely	  to	  result	  in	  transmission.	  The	  focus	  on	  HIV	  for	  sexual	  risk,	  rather	  than	  on	  bacterial	  or	  other	  viral	  STIs,	  is	  primarily	  warranted	  because	  HIV	  is	  not	  curable	  with	  antibiotics	  and	  is	  considered	  to	  be	  life-­‐threatening,	  whereas	  most	  STIs	  are	  not.	  HIV	  risk	  associated	  with	  specific	  sexual	  behaviour	  has	  been	  most	  commonly	  studied	  in	  terms	  of	  the	  per-­‐contact	  risk	  of	  acquiring	  an	  infection	  (Varghese,	  Maher,	  Peterman,	  Branson,	  &	  Steketee,	  2002;	  Vittinghoff	  et	  al.,	  1999).	  	  Based	  on	  these	  and	  other	  epidemiologic	  studies,	  specific	  sexual	  behaviours	  have	  been	  placed	  within	  a	  hierarchy,	  based	  on	  the	  probability	  of	  HIV	  transmission	  occurring	  between	  partners	  of	  unknown	  or	  discordant	  HIV	  serostatus	  (i.e.,	  the	  state	  of	  either	  having	  or	  not	  having	  detectable	  antibodies	  to	  HIV,	  as	  measured	  by	  a	  blood	  test).	  Sexual	  behaviour	  classified	  to	  be	  at	  the	  highest	  level	  of	  risk,	  or	  carrying	  the	  highest	  probability	  of	  transmission,	  is	  unprotected	  penile-­‐anal	  sex	  followed	  by	  unprotected	  penile-­‐vaginal	  sex.8	  Unprotected	  receptive	  penile-­‐anal	  intercourse	  (URAI)	  has	  been	  found	  to	  incur	  the	  highest	  risk	  of	  HIV	  transmission	  (Chmiel	  et	  al.,	  1987;	  Coates	  et	  al.,	  1988;	  Detels	  et	  al.,	  1989).	  A	  higher	  likelihood	  of	  transmission	  to	  the	  receptive	  partner	  is	  thought	  to	  occur	  not	  only	  through	  prolonged	  exposure	  to	  infected	  semen	  by	  the	  rectal	  mucosa,	  but	  also	  by	  rectal	  mucosa	  that	  has	  been	  traumatized	  (Chmiel	  et	  al.,	  1987).	  Although	  the	  majority	  of	  studies	  that	  have	  examined	  HIV	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  8Unprotected	  sex	  means	  that	  condoms	  or	  dental	  dams	  are	  not	  used	  as	  a	  barrier	  method	  to	  prevent	  HIV	  exposure.	  17	  	  transmission	  and	  URAI	  have	  been	  conducted	  in	  MSM,	  several	  studies	  have	  now	  identified	  that	  URAI	  is	  a	  risk	  factor	  among	  heterosexuals	  and	  women	  incur	  the	  greatest	  risk	  as	  the	  receptive	  partner	  (European	  Study	  Group,	  1989;	  European	  Study	  Group	  on	  Heterosexual	  Transmission	  of	  HIV,	  1992;	  Lazzarin,	  Saracco,	  Musicco,	  &	  Nicolosi,	  1991;	  Padian	  et	  al.,	  1987).	  Although	  the	  frequency	  in	  which	  heterosexual	  couples	  engage	  in	  anal	  intercourse	  is	  poorly	  documented,	  several	  studies	  have	  found	  that	  women	  have	  anal	  sex	  for	  a	  variety	  of	  reasons	  including	  to	  enhance	  emotional	  intimacy,	  to	  please	  a	  male	  partner,	  or	  to	  avoid	  violence	  (Maynard,	  Carballo-­‐Dieguez,	  Ventuneac,	  Exner,	  &	  Mayer,	  2009;	  McBride	  &	  Fortenberry,	  2010).	  Billy	  et	  al.	  (2009)	  found	  that	  women	  whose	  male	  partners	  conformed	  to	  traditional	  gender	  roles	  were	  much	  more	  likely	  than	  other	  women	  to	  engage	  in	  anal	  intercourse.	  Several	  researchers	  have	  found	  that	  the	  use	  of	  condoms	  is	  relatively	  infrequent	  when	  people	  engage	  in	  heterosexual	  anal	  sex	  (Billy	  et	  al.,	  2009;	  Halperin,	  1999;	  Maynard	  et	  al.,	  2009;	  McBride	  &	  Fortenberry,	  2010).	  	  	  	   Penile-­‐vaginal	  intercourse	  (PVI)	  poses	  the	  second	  highest	  risk	  for	  HIV	  transmission	  by	  sexual	  activity.	  The	  risk	  has	  been	  established	  through	  epidemiologic	  studies	  that	  have	  examined	  male-­‐to-­‐female	  and	  female-­‐to-­‐male	  HIV	  transmission	  (European	  Study	  Group	  on	  Heterosexual	  Transmission	  of	  HIV,	  1992;	  Nicolosi	  et	  al.,	  1994;	  Padian,	  Shiboski,	  Glass,	  &	  Vittinghoff,	  1997;	  Padian,	  Shiboski,	  &	  Jewell,	  1991).	  These	  studies	  have	  provided	  strong	  evidence	  that	  HIV	  transmission	  through	  unprotected	  PVI	  does	  occur,	  and	  is	  significantly	  more	  efficient	  in	  transmitting	  from	  men	  to	  women—as	  much	  as	  20	  times	  more	  efficient—than	  from	  women	  to	  men.	  	  	   Unprotected	  oral-­‐penile	  (fellatio)	  and	  oral-­‐vaginal	  (cunnilingus)	  sex,	  as	  well	  as	  protected	  vaginal	  and	  anal	  intercourse,	  have	  been	  classified	  as	  low-­‐risk	  sexual	  activities	  for	  HIV	  transmission.	  The	  majority	  of	  research	  examining	  oral-­‐penile	  sex	  and	  the	  risk	  of	  HIV	  transmission	  has	  been	  conducted	  with	  MSM	  (Jeffries	  et	  al.,	  1985;	  Moss	  et	  al.,	  1987;	  Winkelstein	  et	  al.,	  1987).	  These	  studies	  have	  failed	  to	  demonstrate	  an	  association	  between	  penile-­‐oral	  sex	  and	  an	  elevated	  risk	  of	  HIV	  transmission.	  Although	  fewer	  studies	  have	  examined	  the	  risk	  of	  HIV	  transmission	  through	  oral-­‐vaginal	  sex	  (female	  to	  male	  18	  	  transmission),	  because	  few	  people	  practise	  oral	  sex	  exclusively,	  these	  too	  have	  resulted	  in	  the	  conclusion	  that	  oral-­‐vaginal	  sex	  is	  a	  relatively	  low	  risk	  sexual	  activity	  (European	  Study	  Group,	  1989;	  European	  Study	  Group	  on	  Heterosexual	  Transmission	  of	  HIV,	  1992;	  Johnson	  et	  al.,	  1989;	  Lazzarin	  et	  al.,	  1991).	  In	  a	  more	  recent	  study	  of	  heterosexual	  HIV	  serodiscordant	  couples,	  where	  the	  only	  risk	  of	  transmission	  for	  seronegative	  partners	  was	  engagement	  in	  orogenital	  sex	  with	  their	  infected	  partners,	  no	  seroconversions	  occurred	  after	  an	  estimated	  19,000	  unprotected	  orogenital	  exposures	  (del	  Romero	  et	  al.,	  2002).	  Extremely	  low-­‐risk	  practices	  include	  protected	  oral-­‐penile	  and	  protected	  oral-­‐vaginal	  sex,	  mutual	  masturbation,	  and	  wet	  kissing	  (i.e.,	  open	  mouth	  kissing	  with	  an	  exchange	  of	  saliva).	  There	  is	  no	  apparent	  risk	  for	  HIV	  transmission	  from	  touching,	  social	  kissing,	  or	  caressing.	  The	  behaviours	  that	  place	  women	  most	  at	  risk	  for	  HIV	  transmission,	  in	  descending	  order	  of	  risk,	  are	  unprotected	  penile-­‐anal	  intercourse,	  unprotected	  penile-­‐vaginal	  intercourse,	  and	  unprotected	  oral	  (giving	  and	  receiving)	  intercourse.	  Why	  study	  heterosexual	  women's	  sexual	  risk?	  Although	  the	  changing	  context	  of	  dating,	  the	  social	  determinants	  of	  health,	  women's	  biology,	  and	  the	  lack	  of	  HIV	  awareness	  in	  adult	  women	  may,	  in	  part,	  explain	  why	  their	  HIV	  rates	  have	  increased,	  a	  relatively	  unexamined	  but	  important	  aspect	  of	  women's	  sexual	  experiences	  affecting	  their	  sexual	  well-­‐being	  is	  the	  gendered	  nature	  of	  their	  relationships.	  	  Traditional	  sexual	  scripts	  Gendered	  behaviour	  refers	  to	  the	  cultural	  norms	  and	  expectations	  about	  how	  men	  and	  women	  relate	  to	  each	  other	  (Simon	  &	  Gagnon,	  1986;	  Simon	  &	  Gagnon,	  2003).	  This	  behaviour	  can	  affect	  sexual	  experiences	  because	  of	  the	  gendered	  power	  differential	  within	  men’s	  and	  women’s	  sexual	  scripts	  (Emmers-­‐Sommer	  &	  Allen,	  2005;	  Frith	  &	  Kitzinger,	  2001).	  Traditional	  sexual	  scripts	  are	  patterns	  of	  interaction	  between	  men	  and	  women	  that	  are	  expected	  within	  their	  romantic	  and	  sexual	  encounters	  19	  	  (Simon	  &	  Gagnon,	  1986).	  They	  embody	  societal	  conventions	  that	  shape	  people’s	  understanding,	  beliefs,	  and	  actions	  about	  how	  to	  behave	  in	  sexual	  situations;	  they	  consequently	  guide	  people’s	  sexual	  conduct.	  Traditionally,	  men	  have	  been	  socialized	  to	  adhere	  to	  ideals	  of	  masculinity,	  which	  have	  promoted	  them	  as	  the	  aggressors	  and	  initiators	  of	  sex,	  as	  well	  as	  the	  sexual	  decision	  makers.	  Emphasis	  has	  been	  placed	  on	  their	  sexual	  prowess	  and	  personal	  physical	  pleasure.	  Women	  have	  been	  socialized	  to	  adopt	  ideals	  of	  femininity,	  which	  have	  promoted	  sexual	  passivity	  and	  encouraged	  a	  more	  relational	  approach	  to	  sex.	  Accordingly,	  women	  have	  been	  encouraged	  to	  consider	  sex	  as	  acceptable	  only	  when	  used	  to	  express	  or	  achieve	  emotional	  intimacy,	  or	  in	  the	  context	  of	  an	  emotionally	  committed	  relationship	  (Bowleg,	  Lucas,	  &	  Tschann,	  2004;	  Hynie,	  Lydon,	  Cote,	  &	  Wiener,	  1998).	  In	  addition	  to	  being	  cast	  as	  sexual	  gatekeepers,	  heterosexual	  women	  also	  have	  been	  encouraged	  to	  repress	  their	  own	  sexual	  needs	  and	  desires	  in	  favour	  of	  their	  male	  partners’	  (Hynie	  et	  al.,	  1998).	  Women	  that	  endorse	  these	  traditional	  sexual	  scripts	  are	  less	  likely	  to	  communicate	  about	  sexual	  issues,	  disclose	  sexual	  information,	  or	  negotiate	  with	  their	  partners	  about	  the	  acceptability	  of	  various	  sexual	  activities	  (Amaro,	  1995;	  Greene	  &	  Faulkner,	  2005;	  Hynie	  et	  al.,	  1998).	  Some	  studies	  have	  revealed	  that	  this	  is	  an	  important	  factor	  contributing	  to	  the	  rise	  in	  HIV	  in	  women	  (Alexander,	  Coleman,	  Deatrick,	  &	  Jemmott,	  2012;	  Bateson	  et	  al.,	  2012;	  Kalichman,	  Cain,	  Knetch,	  &	  Hill,	  2005).	  	  Adherence	  to	  sexual	  scripts	  restricts	  women’s	  control	  over	  important	  decisions	  concerning	  the	  type	  of	  sexual	  activity	  they	  engage	  in	  and	  their	  agency	  in	  expressing	  their	  sexual	  desires	  and	  what	  they	  find	  to	  be	  sexually	  pleasurable	  (Naisteter	  &	  Sitron,	  2010;	  Philpott,	  Knerr,	  &	  Maher,	  2006).	  Women	  often	  experience	  a	  range	  of	  pressures	  to	  engage	  in	  risky	  sexual	  practices	  or	  those	  that	  are	  not	  necessarily	  pleasurable	  (Holland	  et	  al.,	  1992).	  For	  example,	  they	  may	  comply	  with	  unwanted	  sex	  for	  “the	  good”	  of	  their	  relationship	  (Greene	  &	  Faulkner,	  2005;	  Hynie	  et	  al.,	  1998;	  Katz	  &	  Tirone,	  2009).	  Many	  women	  strive	  to	  maintain	  romantic	  ideologies	  and	  forgo	  their	  own	  physical	  pleasure,	  satisfaction,	  and	  safety	  in	  an	  effort	  to	  satisfy	  their	  male	  partners	  (Jones	  &	  Oliver,	  2007;	  Ortiz-­‐Torres,	  Williams,	  &	  Ehrhardt,	  2003;	  20	  	  Wingood	  &	  DiClemente,	  2000).	  Women's	  motivations	  for	  having	  sex	  (e.g.,	  to	  become	  more	  intimate	  or	  to	  please	  one's	  partner)	  have	  been	  shown	  to	  be	  significant	  predictors	  of	  high-­‐risk	  sexual	  behaviour	  (Cooper,	  Shapiro,	  &	  Powers,	  1998;	  Damani	  et	  al.,	  2009;	  Higgins	  &	  Hirsch,	  2007).	  Because	  women's	  sexual	  scripts	  have	  historically	  emphasized	  the	  primacy	  of	  love,	  trust,	  intimacy,	  and	  romance,	  women	  may	  fail	  to	  negotiate	  with	  their	  partners	  to	  engage	  in	  less	  risky	  sexual	  activity	  and	  the	  type	  of	  protection	  used,	  if	  any,	  for	  fear	  of	  rejection,	  violence,	  or	  ending	  the	  romance	  (Hoffman,	  O'Sullivan,	  Harrison,	  Dolezal,	  &	  Monroe-­‐Wise,	  2006;	  Jones,	  2006b;	  Jones	  &	  Oliver,	  2007).	  Acquiescing	  to	  sexual	  pressures	  negatively	  affects	  discussions	  about	  sexual	  behaviour	  and	  ultimately	  creates	  serious	  barriers	  to	  women's	  sexual	  well-­‐being