Monogamous Halo Effects: The Stigma of Non-Monogamy within Collective Sex Environments
The assessment and curtailment of sexual risk, with an eye toward reduction of sexual disease, is a worthy endeavor, and the pathways for achieving this goal are not always clear. We commend those who research these topics and implement policies based on the best research available to keep the public healthy.
Frank (2018) elucidates the ways in which collective sex environments are maligned, and argues that the unilateral condemnation of these environments is facile. We concur with her assessment. In this Commentary, we extend her analysis to identify the ways in which stigma about non-monogamy influences both the public’s perceptions of, and public health officials’ messages about, sex in general and STDs specifically. Moreover, as Frank’s target article demonstrates, people who direct scholarship and make public health recommendations about risk are themselves embedded in a culture that stigmatizes sexuality (Banaji & Greenwald, 2013). We discuss how they are subject to the biases and prejudices of that culture and need to actively address those biases.
Stigma often arises out of fear of the “other” (Hays, 2013; Liamputtong, 2013), which could certainly include those with STDs or those perceived as high risk for STDs. Unfortunately, health promotion strategies often capitalize on stigma and fear to the detriment of health promotion. Abstinence-only until marriage (AOUM) education, for example, promotes stigmatizing individuals living with STDs and typically shows the worst possible outcomes for anyone who does not follow the heteronormative monogamous route to sex. Yet states in the U.S. employing these tactics have higher rates of unintended pregnancies and see no reduction in rates of STDs (SIECUS, 2009; Stanger-Hall & Hall, 2011). Though the negative outcomes associated with STDs should be taught, failing to give a balanced perspective on sex can be damaging.
By the same token, one of the assumptions about collective sex environments is that they inherently promote risky sexual relations. However, assumptions of sexual risk do not always play out as expected and should be subjected to empirical scrutiny. For example, one study found that among Black males described as “high risk,” using drugs or alcohol during sex was not related to condom-use during intercourse (Crosby, Milhausen, Sanders, Graham, & Yarber, 2014). This is contrary to what one might deem as risky about the situation, making the assumption that drugs or alcohol inhibit risk reduction behaviors. This finding supports Frank’s assessment that judgments of risk about a variety of behaviors (including collective sex) cannot be made unilaterally or without nuance.
Unfortunately, based on research on implicit prejudice, it seems highly likely that those who work in STD prevention fall prey to these biases just as much as the average member of the culture (Banaji & Greenwald, 2013). One important aspect of cultural competence is to constantly and critically question one’s own mental models and approach populations with an open mind (Dreachslin, Gilbert, & Malone, 2013). If public health professionals wish to improve the health of those who are marginalized, they must address stigma people face as a result of participation in a non-dominant culture while acknowledging that they themselves are not immune to stigmatizing the groups that they study. We believe that politically charged issues such as sexuality should be subject to guidelines and regulations that allow researchers to home in on actual risky behavior. That is, precautions should be taken by researchers and public health professionals while undertaking this work to address their own biases.
Monogamy, in particular, is thought to be the gold standard for preventing STDs within AOUM education (Santelli et al., 2017) and more generally (Conley, Matsick, Moors, Ziegler, & Rubin, 2015). Because non-monogamous sex is perceived as inherently riskier, we also associate collective sex environments (and non-monogamy more generally) with greater risk for STDs—this is the issue to which we now turn.
The Monogamous Imperative in Sexual Risk Reduction
Frank (2018) highlights our cultural interpretation of collective sexual environments cogently and incisively. We would like to highlight an underlying theme that Frank did not explicitly identify: the association between collective sex environments and non-monogamy. That is, we believe that a major reason that collective sex environments are perceived negatively is because they violate monogamy norms.
A halo surrounds monogamous relationships such that monogamous people are perceived to have various positive qualities based solely on the fact they are monogamous (Conley, Moors, Matsick, & Ziegler, 2013). For example, in a between-subjects experiment, participants in a predominantly U.S.-based sample rated people in monogamous or CNM relationships on a variety of personality dimensions, including honesty and morality, as well as arbitrary dimensions, such as dental hygiene and tax compliance. People in monogamous relationships were rated more positively on nearly every dimension, including the arbitrary items, which should logically be unrelated to relationship dynamics. These findings suggest that any sexual behavior deviating from monogamy falls outside of this halo effect. Those who engage in non-monogamy suffer adverse consequences, such as social stigma and assumed risk of STDs.
As a counterpoint, consensually non-monogamous people are significantly more likely to use protection with extradyadic partners as compared to ostensibly monogamous individuals who cheat (Conley, Moors, Ziegler, & Karathanasis, 2012; Lehmiller, 2015). Those who are actively non-monogamous (and have an agreement with their partners about their arrangement) use more barrier methods and engage in more testing than those who claim to be monogamous. In summary, monogamy is deemed the best way to prevent STDs, but may provide false safety.
People’s perceptions of collective sex environments are likely affected by the same biases that elevate monogamy. Collective environments are deemed risky precisely because they are associated with non-monogamy. For example, from a public health researcher’s perspective (especially a public health researcher who has been raised in a pro-monogamy environment), one might assume a collective sex environment to be a nightmare—a place of sexual deviance with looming consequences for the health of individuals engaged in activities therein. Those who engage in sex in collective sex environments are likely perceived as more risky and more globally negative than the rest of the population, including by public health officials and researchers.
Similarly, assumptions are likely made that being in a collective sex environment inhibits risk reduction behaviors and makes people more vulnerable to STDs. But of course we know that having sex while others are watching does not increase the STD risk associated with the sexual activity—and engaging in extradyadic encounters is not inherently more risky than engaging in dyadic ones. The only factor that matters in STD transmission is whether the person with whom you have sexual contact has an STD. Beyond that, judgments about risk are operating within the domain of probabilities. The attribution of risk to collective sex environments per se is a logical fallacy. An STD does not care how many people are in the room when sex occurs—just as STDs do not care if the encounter occurs in a committed relationship or a hook-up. STDs can be transmitted even if an individual is monogamous—either because one’s partner is not monogamous or because the partner has acquired an infection prior to the beginning of the monogamous relationship. Even monogamous married people who do not participate in collective sex environments can get STDs—in fact, many spouses have STDs! Thus, collective sex environments are neither uniquely nor inherently risk-laden. Keeping these points in mind is necessary to develop effective measures for the reduction of actual risk.
Reducing Stigma as Health Promotion
The reality is that at least one in two sexually active citizens of the U.S. contracts an STD before the age of 25 (Cates, Herndon, Schulz, & Darroch, 2004). How can we reduce the spread of STDs? The evidence seems clear. Using language, actions, and policies that stigmatize those with STDs contributes to this public health issue, rather than alleviating it, but alleviating stigma surrounding STDs will contribute to their reduction.
Stigma surrounding STDs is negatively associated with STD testing (Cunningham, Kerrigan, Jennings, & Ellen, 2009; Levy et al., 2014; Morris et al., 2014), adherence to medications, and use of health and social services that might lead to treatment of these diseases (Rueda et al., 2016). As a more serious example, the appellation “PrEP whore” for someone who takes pre-exposure prophylaxis to lower chances of contracting HIV is used to stigmatize those who use PrEP (Spieldenner, 2016). Even if someone is in a monogamous relationship with a serodiscordant partner, they may still be called a “PrEP whore” (Spieldenner, 2016). This language places PrEP users on the dirty portion of the dirty/clean binary and lowers their social value. More important from a public health standpoint, this stigma reduces the chance that people will seek prescriptions for PrEP or take those prescriptions.
In sum, working to reduce stigma surrounding STDs seems an obvious matter of public health concern inasmuch as plenty of evidence suggests that by reducing stigma, we could reduce the prevalence of these diseases.
How Bad Are STDs?
We have been discussing stigma and its role in collective sex environments. We would also like to take a step back and ask questions about the rationality of the stigma surrounding STDs. Is getting an STD so horrific that it is fully worth the cultural warnings—or does the negative feeling we attach to STDs perhaps have more to do with the stigma surrounding non-monogamy?
Given the advent of retroviral therapies, HIV (though, of course, a very serious health condition) is no longer a fatal disease—people with HIV have essentially normal life spans with treatment (The Antiretroviral Therapy Cohort Collaboration, 2017). The common flu, by contrast, still kills an estimated 36,000 people per year in the U.S. (CDC, 2017). Yet we rarely see warnings issued for Americans to avoid large group situations (e.g., parties or public events) for fear of contracting the flu—even though the flu clearly is contracted through social contact, as are many other communicable diseases. By contrast, public health officials frequently promote abstaining from sex to prevent people from contracting STDs (Santelli et al., 2017).
To take this analogy a bit further—during flu season—sick people are advised to stay at home. This seems sensible. As a parallel, it makes sense to exhort people with (active outbreaks of) STDs to refrain from sexual activity. However, we, as a culture (including government organizations such as the CDC), go a step further with STD prevention. We intimate that it is really best for everyone not to have sex at all because of the possibility of contracting STDs (Conley, Moors, Matsick, & Ziegler, 2015). This would be akin to suggesting that ideally one would never have contact with people at all, if one wants to avoid catching potentially fatal flu. Such an assertion—though accurate—would seem impractical (it is, after all, more difficult to avoid interacting with people than it is to avoid sexual encounters), but it would also be perceived as excessive. We all accept that we take risks by interacting with people, but that having social interactions despite the possibility of contracting a deadly flu is a worthy risk. Then, why is the remote (assuming safer sex is employed) possibility of contracting a sexual disease an unworthy risk? Does sex not have cultural worth?
Given that in the U.S. we are immersed in a culture that views sex outside of monogamous vanilla sex as sexually risky, we applaud the target article for examining the intersection of location of sex and sexual risk-taking. Frank (2018) argues that it is important to understand the social context within collective sex environments. In this Commentary, we have argued that an underlying theme is that people are generally averse to all non-monogamous sexual encounters. Moreover, we support Frank’s claim that collective sex environments should not be labeled as inherently riskier than other environments in which sex occurs. Rather, it is because we stigmatize non-monogamous sex that these biases are allowed to prevail. Finally, we agree with Frank’s claim that researchers and health practitioners must avoid overgeneralizing. They need to be attuned to both the stigma they place on groups and the stigma those groups experience. Thus, we arrive at a similar conclusion to Frank, the perception of collective sex environments as inherently risky is facile, but add that it is important to address the ways in which our society’s aversion to anything non-monogamous pervades the stigma of collective sex environment encounters.
To this end, we can highlight two takeaways. First, we see the stigma against collective sex environments as one consequence of our culture privileging vanilla sex generally and monogamous sex more specifically. We believe that a cultural emphasis on sexual diversity would alleviate some of the stigma that is associated with collective sex environments. Second, Frank’s response guides researchers to reconsider the premise of whether the risk of STDs is concomitant with the amount of danger that they accord. We raise a more general question: Is the concern about STDs purely about risk to health or is it instead about stigma?
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